Have you ever seen a patient in the hospital and wondered why they were admitted? Not the primary diagnosis at the top of the chart, or the chief complaint, or their exam findings, or the imaging or lab results. Have you ever wondered why they were actually admitted?
In 1993, Michael McGinnis, M.D., M.P.P., and William Foege, M.D., M.P.H., published a provocative paper in JAMA titled "Actual Causes of Death in the United States." They described the modifiable behavioral and lifestyle factors that contribute to mortality. Instead of naming the leading cause of death as ischemic heart disease, they showed that it was the behavior of tobacco use that caused that ischemic heart disease. That model -- considering behavioral and lifestyle factors as proximate causes of death -- views health through a much different lens than the traditional focus solely on disease. It paints a compelling argument for preventive care and demonstrates the importance of considering health outside the walls of the medical establishment.
One can reach even further upstream. Those behavioral risk factors don't occur de novo. Underpinning a person's behaviors is a complex set of circumstances in which they "are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life." That's how the World Health Organization defines the social determinants of health. Social drivers influence the behavior that leads to downstream health outcomes. And those social drivers are what actually cause many hospital admissions.
Physicians write and talk about patients in a way designed to efficiently communicate necessary medical information. Often at the top of a note you will see a brief assessment. A recent one-liner from our family medicine service read: "A 34-year-old female with a history of epilepsy presents after having multiple seizures at home, found to have acute renal failure likely secondary to rhabdomyolysis, complicated by dental injury requiring extractions and a shoulder subluxation."
Let's do a thought experiment to find the actual cause of admission. She was admitted to treat acute renal failure. And what caused that? Multifactorial pathophysiology from a cluster of seizures. And what caused that? She wasn't taking all her prescribed medications. And what caused that? She couldn't afford the second anti-epileptic agent she was recently prescribed.
The one-liner reads quite differently if we look at her through the lens of the systemic drivers that caused this admission: "A 34-year-old woman with a history of epilepsy presents with multi-system damage secondary to an inability to afford her anti-epileptic medication and subsequent breakthrough seizures, now missing work for seven days and discharged with a massive hospital bill."
In this case, the prohibitive cost of one medicine led to an entire hospitalization. How do those costs compare?
This patient was having breakthrough seizures on zonisamide. Approximate cost: $25 per month. A second agent, lacosamide, was then added. The cost of this second agent varies from roughly $1,000 per month with GoodRx to $50 per month on many commercial insurance plans like the one this patient has. That's the preventive cost.
Healthcare Bluebook estimates a "fair price" for this patient's seven-day hospitalization for acute renal failure to be $12,900. Beyond these direct costs, there is ample room for imagination. There would be costs if she developed permanent kidney damage, which also could limit which anti-epileptic drugs she could use in the future. There would be costs if she has sequelae of the two teeth extractions she had after sustaining dental injuries during her seizures. There would be costs if she develops premature shoulder osteoarthritis after recurrent acromioclavicular injuries and shoulder subluxations. Until her seizures are controlled, there would be costs if she struggles with transportation and employment. And this doesn't begin to address the impacts on this woman's quality of life or the consequences of missing a week of work.
It's easy to see that spending $50 monthly in order to save $12,900 -- and potentially a lifetime of physical and financial effects -- is a great deal. But only if you have insurance. And only if you can afford an extra $50 a month.
This thought experiment leads to an inevitable realization: As physicians, we can treat acute renal failure for the rest of our careers and never fix the actual cause of this patient's admission. As physicians, we are uniquely positioned to be community leaders, advocates for systemic policy changes, champions of quality improvement and teachers to the next generation of physicians. It is our responsibility to look through the lens of systemic drivers when we're treating patients and working to improve the health of our communities. So the next time you see a patient on the wards -- or in the clinic or the operating room -- ask yourself: What actually caused your patient's health issue? What social drivers caused the upstream behaviors that led to now? And more importantly, what are we going to do about it?
Kyle Leggott, M.D., is a family physician doing a fellowship in health politics and policy at the University of Colorado. You can follow him on Twitter @KyleLeggott.
Graham Custar, M.D., is a recent graduate of the University of Colorado School of Medicine who has matched to the family medicine residency program at Mountain Area Health Education Center in Asheville, N.C.