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Before utilization review and managed care, and when a night in the hospital cost much less than now, we could take our time about turning an inpatient back into an outpatient. Furthermore, in the past the same physician usually maintained continuous care of the patient from office to hospital and back again, while now a hospitalist usually takes care of the hospitalized patient.
As I implied in this post this has the potential to create substantial tension between the hospital and the outpatient physician at the time of admission. It has since occurred to me that even more tension can develop around the patient’s return to the office practice. This struck me in particular when I read of a case in which an office-based physician complained that the hospital accomplished little more than adding aripiprazole to the patient’s antidepressant regime during a too-short stay, raising doubts about the patient’s true readiness to leave hospital. The financial motive of the hospital increases pressure for quick intervention and discharge, while potential liability (admittedly shared by the hospital) might make the office-based physician worry about the patient’s safety. I see this conflict as supportive of my contention that, at the office physician’s discretion, we might deem the patient’s care to have transferred indefinitely to the hospital physician, placing the burden on the hospital to convince the receiving physician of the patient’s readiness for outpatient management.
It soon occurred to me, though, that I rarely hear of problems arising out of too early discharge. How often does this actually happen? How often does it make for an unhappy office-based physician, and, even more important, how often does premature discharge lead to an adverse outcome for the patient?