28 Jul Making Profound Changes from an Office Visit
By Adam Philip Stern, MD
Mr. D was my patient in the partial hospital program for the chronically and persistently mentally ill, and he was barely maintaining the level of functioning necessary to remain outside of the inpatient unit. A middle aged man with long-term psychotic and depressive symptoms, Mr. D’s care was made even more complicated by an extensive history of alcohol dependence and intravenous drug use that had left him with a severely damaged liver. A combination of hepatitis C viral infection and long-term daily alcohol use had left his body without the tools most of us take for granted in being able to metabolize and excrete the multitude of non-lethal toxins we all ingest and produce on a daily basis.
His long-term prognosis was poor, but in the context of his treatment at the partial hospital even the very short-term health and well-being of this patient remained very much in doubt. The liver disease was contributing all of the symptoms associated with hepatic encephalopathy — confusion, lethargy, difficulty coordinating his movements, impairments in attention and concentration.
The prescribed solution to that point was an old medication called lactulose which helped reduce the amount of ammonia in his blood stream by removing it through excretion in the colon; the consequence of this remedy was frequent diarrhea to the point of fecal incontinence. Mr. D would at times soil himself in the presence of others and became intensely ashamed of this result to the point that he began covertly refusing to take his medications.
It wasn’t long before the ammonia in his body built up to the point that his symptoms were out of control. He was entirely disoriented and was unable to perform even the most basic activities of daily living. He needed to be hospitalized at great expense just to bring him back to his already limited baseline. When he was discharged from the hospital, his discharge paperwork had on it a follow up appointment with a liver specialist in several days. I tried to imagine Mr. D fully explaining the issues surrounding his treatment and had difficulty feeling comfortable that the necessary information would be conveyed.
With his permission, I decided to join the patient at his appointment not out of the goodness of my heart but rather a thirst for efficacy. Together, he and I were able to piece together all of the problems he had been having in tolerating the lactulose and explained why he found it too difficult to take regularly. The liver specialist appreciated his dilemma and decided to try a different medication called rifaximin, with equal efficacy but many fewer side effects. The medication is not a first-line treatment because it is on patent and very costly. But, the liver doctor assured us, the patient had now officially failed the lactulose and would qualify for the rifaximin with her advocacy.
Within days, Mr. D was taking rifaximin regularly and benefiting marvelously from the improved tolerability. Not only did his physical health improve, but it allowed for him to actively participate in the mental health treatment at the partial hospital day program. It was truly a life-changing intervention for this man.
When thinking about the system in place that nudged Mr. D and me down our common path, I couldn’t help but notice that the fear of increased cost in the short term (i.e. the policy dictating lactulose as a first line treatment in this patient over rifaximin) resulted in an increase in systemic costs when he required inpatient hospitalization. It seems in keeping with recent systemic efforts to determine what is the right treatment in the right place at the right time. My own low-tech intervention of escorting Mr. D to his appointment was equally evocative in my mind. It is apparent that relatively simple changes in the way we deliver healthcare have the potential to make profound changes in the outcomes we achieve.
Adam recently finished his residency in psychiatry at the Harvard Longwood Psychiatry program. He is now an Instructor of Psychiatry at Harvard Medical School, and the Director of Psychiatric Applications in the Berenson-Allen Center for Non-invasive Brain Stimulation at Beth Israel Deaconess Medical Center. He was also a contestant in the 2013 Costs of Care Essay Contest.