The Patient with Complex Problems (Case 3)
William D. Surkis MD
Case: The patient is a 62-year-old woman with a past medical history of hypertension, gastroesophageal reflux, atrial fibrillation (not on anticoagulation because of medication nonadherence), end-stage renal disease on hemodialysis, nonischemic cardiomyopathy with ejection fraction of 40%, status post (S/P) automatic implantable defibrillator placement, and aspirin allergy who presents for a follow-up appointment one week after hospital discharge. The only information you have is in a short notation that was made at the time the appointment was given: “Had TIA [transient ischemic attack] at Elsewhere General Hospital.” Discharge paperwork is unavailable. The patient’s chief complaint was recorded by the appointment secretary as: “I had a stroke, and now I can’t pay for the pills they gave me.”
The Patient with Complex Issues: A Problem List
|
Hypertension |
S/P automatic implantable defibrillator placement |
Gastroesophageal reflux |
|
Atrial fibrillation |
Allergy to aspirin |
Medication nonadherence |
|
Nonischemic cardiomyopathy |
End-stage renal disease (on hemodialysis) |
S/P sigmoid colectomy for diverticulitis |
Encountering a patient with so many active medical conditions is anxiety provoking. Under such circumstances I try to remember to (1) breathe deeply, (2) convey warmth and reassurance, (3) confirm current symptoms, and (4) gather information.
Always begin a visit by conveying warmth (“How are you? We haven’t seen you in a while and I heard you’ve been through a lot!”) and reassurance (“We will straighten out the issues with your medications”).
Confirm the patient’s current symptoms: Is she having any active symptoms at this time? If this were the case, the goal of the appointment would immediately shift to focus on her acute medical problems.
Gather information. If your patient’s recent care took place at an outside hospital that is not associated with your practice, have the patient fill out the appropriate forms to release her medical information to your office. With time in short supply during a primary-care visit, the three most helpful pieces of paperwork to obtain would be (1) a copy of her hospital history and physical, (2) her recent discharge summary, and (3) her discharge paperwork and/or medication reconciliation form. These forms should allow you to confirm the details of her hospitalization, obtain information on tests and lab findings during hospitalization, and ensure that she leaves your visit on the correct medications. A call can also be made to the patient’s pharmacy to obtain a list of the most recently prescribed medications.
I generally avoid trusting patient descriptions of medications (e.g., “the little, round brown pill”). If unidentified pills are brought in by the patient, they can be identified using free online resources such as the drugs.com “Pill Identifier” (http://www.drugs.com/pill_identification.html). Many emergency departments have access to electronic medical records and may be able to confirm or deny critical medications if other sources are closed or unavailable.
The number of patients with complex problems being seen today is significant. As we do a better job of saving lives during acute illness, we create more chronically ill patients, with an ever-increasing number of illnesses, who can be on many medications. It is important to ensure that adequate systems are in place in hospitals to complete proper medication reconciliation, and to communicate discharge medications and patient plans of care with primary-care physicians.
PATIENT CARE
Clinical Thinking
• This is a worrisome patient. She has a complex medical history and recent new issues.
• Obtaining paperwork from the hospital and pharmacy is always a priority.
History
• Sort out acute matters first:
• What changes may have brought her to her appointment today?
• Try to determine if her symptoms resolved before she reached the hospital.
• Does she still have any of the symptoms that brought her in?
• Review the problems that you know about:
• Ensure that she has been going to hemodialysis.
• You know she had atrial fibrillation in the past, so you can ask about palpitations.
• You know she has an implanted defibrillator, so you can ask about shocks.
• Work backwards using any clues provided:
• This patient has been on warfarin in the past; ask her if she is back on warfarin or Coumadin (remember that many patients know medications by only one name; there are no guarantees if this is the brand or generic name!), or a “blood thinner.”
• Ask about related problems for which she may be high risk.
Physical Examination
• Start with vital signs and weight.
• Compare the patient’s weight to her previous weights checked in the office.
• Listen for rales and evidence of pleural effusion.
• Look for lower extremity edema.
Tests for Consideration
My major caveat here is to recommend avoidance of ordering new lab tests or doing new radiologic studies at this time. It is likely that this patient has recently had numerous blood tests and multiple imaging studies during her recent hospitalization. As these results should be obtainable within 24 hours, in principle it is wise to refrain from ordering new (and potentially unnecessary) lab tests at this time unless another acute problem has appeared.
Follow-up
Practice-Based Learning and Improvement: Patient Safety
Ensuring adequate medication reconciliation on admission to and after discharge from the hospital is a critical patient safety intervention.
Creating an office-based system to accomplish or facilitate this is a superb opportunity for improving your patient care and enhancing your patients’ safety.
Consider creating medication reports for all patients in your practice that patients can keep in their handbags or wallets for use when admitted to the emergency department or the hospital.
Patients should be educated on how critical it is that they have knowledge of their medications. Encouraging patients to be their own medication safety advocate—by insisting that all medication changes be written down and provided to them—can be a huge benefit. Ensuring that patients bring all pill bottles to every office visit can also work toward this goal and help prevent medication errors.
Carefully reviewing all medications provided to patients who have just been discharged from the hospital is vital. Many patients are discharged on PRN (i.e., as needed) medications they do not need and that could cause side effects.
Do not be afraid to remove medications that have become unnecessary; you will keep your patients healthier! Consider semiannual medication “audits” on all of your patients (whether their issues are complex or not) and review all their medications to see if any can be discontinued.
Professionalism
It is important to make discussion of financial issues with patients a nonjudgmental conversation that focuses on the medical issues, keeping discussions of finances (as much as possible) in the background. When filling out pharmaceutical assistance program or Medicaid paperwork, it is of utmost importance to be truthful. For example, if a Medicaid form asks if a patient is employable and he or she is, you must state this, even if doing so will result in your patient not receiving the sought-after benefits. Filling out such forms untruthfully constitutes Medicaid fraud.
Help Patients Obtain Their Medications
It is imperative that we assist our patients in filling prescriptions after office visits to control their disease and prevent the likelihood of new complications. Attention must be paid to patients’ insurance plans. Their medications should be prescribed from their insurance company’s drug formulary or from generic drugs. Many insurers require “preauthorization” for some medications, a process in which the physician completes a form documenting why this particular medication (and not a cheaper medication) must be prescribed for the patient. Although preauthorization can take time, almost every insurer provides an “emergency supply” of the medication while the process is taking place. In the event a patient has no medical insurance, use of a prescription assistance program such as PPARx, the Partnership for Prescription Assistance (http://www.pparx.org), or a drug manufacturer’s prescription assistance program, will be critical. If necessary, assist the patient in applying to the state Medicaid program, understanding that applications can take up to 60 days to be approved (http://www.bmspaf.org/pdf/2010_Individual_Application.pdf).
Patients’ options may be limited to self-pay for limited amounts of the medication (e.g., purchasing a 14-day supply in hope of being approved for an assistance program rapidly) or to the physician’s providing the patient with sample medications. Some stores have formularies that carry a 30-day supply of many medications for a fixed price of between $4 and $10. Unfortunately, some patients may need to ration their health care dollars and choose which medications they should take and which they must take.
Suggested Readings
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Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004;364:331–337.
Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:227–276.
Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med 2010;170:1648–1654.
Hilliard AA, Weinberger SE, Tierney LM Jr, et al. Clinical problem-solving: Occam’s razor versus Saint’s Triad. N Engl J Med 2004;350:599–603.
Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med 2001;38:666–671.
Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000;284:2901–2906.
Kuo Y, Sharma G, Freeman JL, Goodwin J. Growth in the care of older patients by hospitalists in the United States. N Engl J Med 2009;360:1102–1112.
Lindenauer PK, Rothberg MB, Pekow PS, et al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med 2007;357:2589–2600.
Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc 2005;80:991–994.
Meisel S: Falling through the cracks: medication reconciliation at admission and discharge. Pharm World Sci 2008;30:92–98.
