Dr. Berry’s Snippets

Cost-effective care at its clinical best

A 50-year-old woman with abdominal pain who potentially required surgery saved at least $4,600 in one visit at our practice by avoiding an ER visit.  She saved an ER charge for evaluation of abdominal pain including the doctor’s fee, facility fee, and lab tests (at least $2000) and the facility and radiologist’s fee for a CT scan ordered from the ER (at least $3000).  Instead she paid $400 for the CT scan at a non-health-system-based facility in Knoxville. She did not need surgery after all.

Here is the rest of her story.

A few months ago, this relatively new member appeared in our office early one afternoon accompanied by her husband with right lower quadrant abdominal pain for 5 days that had started rather abruptly and eased off slightly by the time she decided to come in.  This is not how appendicitis typically presents, but I have learned over the years (and have the gray hairs to prove it) that few patients are textbook cases.  She didn’t have any other symptoms that would go along with bad things that cause severe right lower quadrant abdominal pain such as the nausea & vomiting of appendicitis or of a kidney stone.

On exam, she had moderate pain in the area of the appendix when I pressed on it, not in the area of the right ovaries.  She is a little old for an ovarian cyst rupture and while the pain does come on abruptly with rupture of an ovarian cyst it usually subsides completely over a day or so.  And she had what we doctors call “peritoneal signs,” which means that she hurt in that area when I slowly pressed down on her left side then pulled my hand up quickly.  It hurt in the right lower part of her abdomen when she coughed, which is also a “peritoneal sign” indicating inflammation of the sac surrounding the intestines and consistent with appendicitis.

Could this be an atypical presentation for appendicitis?  I remembered another patient from about a decade before who had pain on and off for about a month in his right lower quadrant who finally presented to our office and I was surprised to find that he had appendicitis once we obtained a CT scan. Could she be like him?

I don’t like taking chances when there is a possibility of catastrophe such as a ruptured appendix – which can be fatal.  So, I recommended she go immediately to the ER.  She and her husband asked if there was another option.  We called a private radiology facility in Knoxville where we have been able to get same day CT’s for $400 and they had one availability that afternoon – but it was in one hour, and there was no way they could get there in time.

So, again I recommended they go to the ER.  The husband chimed in and complained that he was still paying on a $900 ER charge for treatment of a gout attack from several months back.  I told them that the safest thing to do would be to go to the ER where a CT scan would be done that afternoon and then surgery if necessary or sent home if not.  They asked me what I thought the odds were that she had appendicitis.  I said about 50/50 considering that her pain had slowly improved.  But those weren’t good odds considering she might have a problem that could be fatal.

Understanding these odds, they decided to wait until the next morning to have the CT in Knoxville willing to take their chances that if it was an infected appendix it wouldn’t rupture by then.  So, we scheduled it at 9AM with instructions that if her abdominal pain got worse to go straight to the ER.  I told them that we usually received a fax with the radiology reading within a half hour after the test, so they should stay in Knoxville until I called them with the results.  If she did have appendicitis then she needed to go to UT Knoxville, the nearest hospital, which they said they preferred over Ballad anyway. 

We drew labs for a complete blood count and complete metabolic panel ($15 total) in case we needed this information after the CT scan.  Her visit with me didn’t cost anything because she was a member and the visit was during office hours.

She had the CT scan the next morning, and it revealed a very unusual problem, especially to occur in the right lower part of the abdomen – epiploic appendagitis – that only rarely requires surgery.  So, she returned home and took ibuprofen to ease the pain which gradually went away over the next 10 days.

Once again, cost effective care at its clinical best!