Peri-hospital care: time to have a system for arranging patient care before and after hospitalization
Twenty years ago, a friend of my father, suffering from pancreatic cancer, came to a famous hospital in Beijing from my hometown for surgery. While waiting for hospitalization, his wife, a retired nurse, came to me for help, saying her husband was very weak, and she wanted me to prescribe some take-home normal saline and glucose solution for patient infusion during their hotel stay. I did the favor, but asked her why not asking the doctors in that hospital to prescribe these drugs. She said that no one would care about such things. She didn’t even dare to let the doctors in charge know that she would give patient these treatments without permission, which would irritate them.
Through this experience, I realized that, for patients, coming to Beijing for surgery is not easy. Not only do they have to wait humbly and patiently for a hospital bed in this unfamiliar city, but also deal with various medical problems before and after hospitalization. The above-mentioned patient’s wife was a nurse and could handle treatments like infusions, but what about other people? Besides, many medical problems are difficult to solve even for a doctor or nurse.
Twenty years later, have we improved our basic out-of-hospital medical services for those with cancer and critically ill patients before and after hospitalization? To be fair, there has been some improvement, but the extent appears to be very limited. The ordeal of a patient with colon cancer and liver metastases who came to me for help provided evidence for this negative judgment. The patient had undergone surgery and a standard course of chemotherapy at a major oncology hospital in a provincial capital city. However, at discharge, he was given no further detailed medical guidance, and consequently he did not closely follow up his diseases. By the time he came to me, the liver tumor recurred and progressed to an intractable level.
These two examples shed light on a blind spot of our hospital system over the years: We have focused our efforts and resources on the diagnosis and treatment during hospitalization, while often fail to provide adequate medical care before and after hospitalization for patients, especially those with tumors or other severe diseases. Moreover, given the highly specialized professional knowledge required, many patients discharged back into the community were at the mercy of luck, as no one knows how to take care of them, and follow-up visits are often missed, not to mention the more advanced care of psychological support, financial guidance, language services, etc.
In China, with the development of the high-speed railway systems, travel between cities and towns is becoming ever more convenient. Cancer patients and seriously ill patients crowd into central cities such as Beijing and Shanghai to seek better medical services. In these places, the discontinuity between inpatient medical services and pre-hospital and post-hospital services is more prominent, so a solution to these problems is particularly imperative.
In current China, where public medical system is predominant, medical authorities do not seem to pay enough attention to this issue. Among the many indicators that they laid down for hospital evaluations, perhaps only one of them labeled as “patient satisfaction” implicitly touches on a hospital's ability to solve this problem. Under this evaluation system, presidents and department chairs of large and medium-sized hospitals are pressured to focus not only on revenues but also indicators such as total number of hospitalized patients and proportion of big and medium operations, etc. When priorities were given to these evaluative indicators with dubious validity, who is there to care whether a patient has been given proper medical care before admission, whether wound pain needs to be relieved by medication after discharge, or whether follow-up visits be done on time?
The Chinese medical authorities have been attempting to establish a more reasonably graded medical system, allowing patients to get continuing medical services suitable for their diseases. However, the current system under construction does not help much in solving the above problems. The incompatibility of health information systems of various medical facilities alone is already a huge barrier to cross for medical institutions to network. In addition, each medical institution is an independent legal entity managed by different government departments, which further increases the difficulty of resource integration and collaboration.
Is this really an unsolvable problem, given the circumstances above mentioned? Surely not. China is now ranked second in the world in overall economic power. Not only does China have a large and powerful medical administration, but also an incredible social governance and control system. Why can’t we learn from the various coordination mechanisms formed during the COVID-19 pandemic, which efficiently “locked down” cities with millions of people overnight, and carry out national-level design work to establish a truly effective graded medical system to solve the problem?
As the old saying goes, “rocks from other hills may serve to polish jade”. In developed countries such as Japan, a medical system with public hospitals as the main body has long been established, and the Commonwealth countries represented by Canada and Australia also established a mature referral system between family doctors, local clinics, central hospitals, specialist physicians. China’s medical authorities surely should and can draw lessons from experiences that these foreign counterparts have accumulated in medical system design through years of exploration and practice. China is now fully capable of establishing a graded medical system that’s comparable to those in developed countries, which promise a solution to the discontinuity between inpatient services and pre-hospital and post-hospital medical services.
Regardless top-level design and implementation paths, to establish an effective graded medical system, the most critical is sufficient funding, especially for the local medical departments, so as to attract competent medical workers to devote themselves to primary medical services. One of the key reasons why the current graded medical system is not so successful is that local medical departments have been under funded, shaking the foundation of the grade medical system. On the other hand, hospitals, especially large and central ones, should also commit efforts to designing more humanized clinical pathways, and proactively connect pre- and post-hospital support for patients.
Another solution is to open the pre-hospital and post-hospital supporting business services to private institutions. The market demand is far from being met. Recently, a popular “consultation accompany” service, which means accompanying the patient to see a doctor, has emerged among the middle classes in Beijing and other big cities, a clear sign of the need for such services. If this new type of business can be gradually developed, an effective market-based solution to the above problems may be insight. Or, at least, it will provide a useful supplement to the graded medical system dominated by public medical care.
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Hepatobiliary Surgery and Nutrition. The article did not undergo external peer review.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-22-546/coif). The author has no conflicts of interest to declare.
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