Treating symptoms, not the disease

The backlog in emergency rooms in Manitoba stems from problems before and after the ER, not in the ER.

In Tom Brodbeck’s piece on the chronic and rising emergency room crisis in Winnipeg (Condition critical, Aug. 21) he quoted several experts who alluded to the backlog of accessible beds, beds needed so that acutely ill people can be moved out of the ER onto hospital wards.

This is a problem of an acute-care bed shortage in the acute-care hospitals and a long-term care bed shortage outside of the acute-care hospitals, where patients who no longer need acute care should be.

One major problem not addressed in Brodbeck’s article is the care required to reduce patients’ perceived or real need to come to the ER.

Chronic diseases, especially chronic immune diseases, have been on the rise for decades. In fact, several researchers at the University of Manitoba have reported on Manitoba having among the highest incidence rates of certain chronic immune diseases, such as inflammatory bowel disease and multiple sclerosis, in the world.

These diseases are often treated by expensive, advanced therapies (biological and small molecule drugs). These drugs have revolutionized care so that patients have better outcomes.

But the dosing, potential adverse effects from these drugs and monitoring of these drugs requires special expertise. When these patients show up in the ER, the nursing and physician staff will require specialist input for these patients, further backlogging the ER.

So how do we keep patients with chronic diseases from attending the ER?

One problem in Manitoba is that when these expensive drugs were approved for use, the government established the exception drug status (EDS) program, whereby doctors have to apply on behalf of patients for the government insurance to cover the post-deductible costs of these drugs.

The government believes that a firewall such as EDS saves it money by preventing inappropriate prescriptions of these drugs. Stubbornly, and to the detriment of patient care, the government EDS program has maintained outdated, 25-year-old standards that need to be met before the drugs are approved.

Getting patients the necessary therapy is delayed, patients’ acute conditions deteriorate and they end up in the ER.

A second problem of Manitobans with chronic diseases is an inability to contact expert nurses or doctors who can advise them on their acute or sub-acute problems.

At the Health Sciences Centre, we established a nurse practitioner program that was available to Manitobans with inflammatory bowel disease and we accrued evidence over two years that this program kept patients from attending the ER.

Nonetheless, the government failed to fully fund the program and so it has collapsed. A nurse practitioner model provides excellent, experienced care in chronic diseases, at fixed costs.

All chronic diseases, whether immune-mediated or not, should have call centres for patients to access (especially after hours) that will reduce their need to show up in ERs.

Opening up one or three new ERs in Winnipeg will not solve the ER crisis.

Right now, with double-digit wait times, patients often choose to stay home and wait it out.

When wait times drop to single digits, and/or when new ERs open up, more patients will attend ERs. The individual wait times will appear shorter. This number (ER wait times) will look better, but it will come at a much higher ER cost to the system — more patients attending the ERs, staffed by more health-care providers, reducing the availability of health-care providers to manage chronic diseases.

The population is aging and living longer with multiple morbidities.

Chronic diseases are rising.

The government needs to meet with physicians on the front lines of chronic disease patient management and hear innovative ways to make Manitobans healthier. We need to reduce patients’ needs to attend the ER.

Then the ER crisis will start to ebb.

Charles N. Bernstein, MD, is a distinguished professor of medicine at the University of Manitoba.