The Root of the Problem
2021; Lippincott Williams & Wilkins; Volume: 14; Issue: 9 Linguagem: Inglês
10.1161/circoutcomes.120.007750
ISSN1941-7705
AutoresRaymond Y. Yeow, Sami El‐Dalati, Edward A. Jouney, Janice Firn, G. Michael Deeb, Matthew C. Konerman,
Tópico(s)Healthcare cost, quality, practices
ResumoHomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 9The Root of the Problem Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessResearch ArticlePDF/EPUBThe Root of the Problem Raymond Y. Yeow, MD, Sami El-Dalati, MD, Edward A. Jouney, DO, Janice I. Firn, PhD, MSW, G. Michael Deeb, MD and Matthew C. Konerman, MD Raymond Y. YeowRaymond Y. Yeow Correspondence to: Raymond Y. Yeow, MD, Frankel Cardiovascular Center, Michigan Medicine, 1500 East Medical Center Dr, Ann Arbor, MI 48109. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0985-3758 Division of Cardiovascular Medicine (R.Y.Y., M.C.K.), Michigan Medicine, Ann Arbor. , Sami El-DalatiSami El-Dalati https://orcid.org/0000-0003-2603-2951 Division of Infectious Diseases, University of Pittsburgh Medical Center, PA (S.E.-D.). , Edward A. JouneyEdward A. Jouney Department of Psychiatry (E.A.J.), Michigan Medicine, Ann Arbor. , Janice I. FirnJanice I. Firn Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor (J.I.F.). Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor (J.I.F.). , G. Michael DeebG. Michael Deeb Department of Cardiac Surgery (G.M.D.), Michigan Medicine, Ann Arbor. and Matthew C. KonermanMatthew C. Konerman Division of Cardiovascular Medicine (R.Y.Y., M.C.K.), Michigan Medicine, Ann Arbor. Originally published14 Sep 2021https://doi.org/10.1161/CIRCOUTCOMES.120.007750Circulation: Cardiovascular Quality and Outcomes. 2021;14In this edition of our series, we will present a case highlighting the complexities of caring for patients with endocarditis occurring in the setting of intravenous drug use and psychiatric illness. We will emphasize the need for improved systems to treat patients with substance use disorders.Learning ObjectivesReview key concepts of substance use treatment in the setting of endocarditisAppreciate treatment gaps and possible biases affecting patients who inject drugs and endocarditisRecognize the role of a multidisciplinary team in the treatment of injection drug use-associated endocarditisCase PresentationA woman in her 40s presents with altered mental status. Her history includes opioid use disorder (OUD) with intravenous heroin. She has received medication-assisted treatment (MAT) on 4 occasions. She also has a history of substance use including cocaine and benzodiazepines. She has several social stressors including homelessness with food insecurity and limited social support. She is also the mother of 3 children, who are all presently in foster care.She is found to have a new diastolic, decrescendo murmur along with scattered petechiae. Computed tomography reveals evidence of embolic infarcts to the brain, kidney, and spleen. Blood cultures are obtained and intravenous antibiotics are initiated; cultures ultimately grow Group C Streptococcus. The patient is intubated for altered mentation and started on vasopressors. Echocardiography demonstrates moderate-to-severe aortic regurgitation with paravalvular inflammation of the aortic root and a 2-mm mass on the aortic valve.This patient presents with septic shock from infective endocarditis (IE), likely related to her history of injection drug use (IDU). Her clinical presentation raises unique management challenges as her history of IDU must be treated just as seriously as her IE to achieve optimal outcomes. Unfortunately, the incidence of IDU-associated IE has risen over the last couple of decades, comprising up to 22% of all IE cases.1–4 One of the main drivers for the rise in IDU-associated IE has been the worsening opioid epidemic. Care for patients with IDU-associated IE has been linked with increased length-of-stay, higher rates of readmission and recurrent IE, and subsequently increased cost of care.5 Therefore, it is important for health care providers to understand the various facet related to managing IDU-associated IE and to develop therapeutic relationships with patients to facilitate optimal treatment of IDU.The extensive aortic root and valve involvement will require this patient to undergo surgical management in addition to a several-week course of intravenous antibiotics. Class I indications for surgical management of IE include valvular dysfunction causing heart failure, IE caused by a resistant organism, heart block or abscess, persistent infection, and patients with relapsing prosthetic valve IE.5 Other considerations (Class II) for surgical intervention include mobile vegetations >10 mm with or without embolization, recurrent embolization after antibiotic therapy, and persistent vegetation despite appropriate antibiotic therapy.5 In general, surgery should be performed early unless patients have evidence of ischemic stroke with extensive neurological damage or intracranial hemorrhage, or if patients have low life expectancy and/or multiorgan failure.5,6 Pending further neurological evaluation and investigation into her IDU history, this patient would likely benefit from an aggressive early surgical approach.On hospital day 5, the patient is extubated and her mental status improves. She wishes to pursue surgical intervention and commits to completing her antibiotic course as an inpatient. She also is willing to initiate MAT for her OUD during her inpatient stay. Psychiatry is consulted and plans on starting buprenorphine post-operatively while also providing referrals for outpatient management of buprenorphine.With improvement in her clinical and mental status, surgical management to achieve source control and definitive management of her valvular dysfunction is the most appropriate next step for treating her IE. However, understanding the patient's history of OUD and IDU is prudent to identifying barriers that may limit her overall clinical outcome. Patients with IDU-associated IE have been demonstrated to have high rates of recurrent drug use after valve surgery.4,7 Furthermore, recurrent drug use can lead to recurrence of IE, and subsequently increased mortality among patients who inject drugs (PWID).8–11 Unfortunately, these poor outcomes are often precipitated by loss to follow-up and concerns surrounding adherence to medical therapy. Attempts to mitigate this have included hospitalizing patients for the duration of their intravenous (IV) antibiotic course. However, this increases hospital length-of-stay and may invoke post-traumatic stress disorder in patients who are experiencing withdrawal symptoms or anxiety relating to their prolonged hospitalization. The option to complete IV antibiotics as an outpatient has been marred by the perceived risk of recurrent IDU and catheter misuse. However, this notion has been demonstrated to be inaccurate, with mortality rates and catheter-related complications that are comparable between PWID and patient without IDU.12,13On hospital day 10, the patient receives an aortic root and aortic valve replacement. It is determined that outpatient administration of intravenous antibiotics is too high risk in the setting of a history of IDU. Plans are made for 4 weeks of inpatient ceftriaxone. Meanwhile, multiple referrals are made to outpatient providers for buprenorphine management. On hospital day 15, she insists on being discharged. Psychiatry determines that she possesses decision-making capacity. Despite emphasizing the risks of leaving the hospital, the patient decides to leave against medical advice with oral amoxicillin therapy and declines further assistance with arranging buprenorphine maintenance therapy; buprenorphine had yet to be initiated as an outpatient prescriber had not been established.The initiation of MAT during a medical hospitalization has been shown to be beneficial when compared with opioid detoxification alone.14,15 However, MAT use in medically hospitalized patients with IDU-associated IE demonstrates less favorable outcomes.16 Referring such patients to outpatient substance use disorder (SUD) treatment programs at discharge may improve outcomes. Rodger et al17 showed decreased IE mortality was associated with referral to addiction treatment services. However, only 19.8% of their cohort received referrals for SUD treatment, which underscores the recurring finding that outpatient addiction treatment services are underutilized in this inpatient population.17,18 Given the combined lethality of IDU and IE, the medical team appropriately offered to initiate buprenorphine during the hospital stay with plans to identify an outpatient buprenorphine provider.Another MAT option that could have been considered is methadone. However, it raises similar challenges as a federally certified methadone clinic would need to be identified to dispense this medication post-discharge. The third and final MAT option for the management of opioid addiction is intramuscular naltrexone, which was approved for treatment of OUD by the Federal Drug Administration in 2010. Naltrexone as a treatment intervention has not been studied as extensively compared with buprenorphine and methadone. However, the option for an extended-release intramuscular formulation that can help to mitigate cravings for up to 4 weeks is attractive and could conceivably help combat adherence problems.19While it was determined that the patient's decision-making capacity was intact, her reasoning for leaving against medical advice was not thoroughly evaluated. A hospitalization can be quite unsettling for patients with OUD, and it has been shown that SUDs are strongly associated with against medical advice discharges.20 This is likely due to multiple factors including withdrawal symptoms, severe cravings, a perceived antagonistic relationship with the treatment team, and a sense of confinement. Although oral antibiotics may have been sufficient to treat her IE after surgery, the inability to identify an outpatient prescriber and initiate buprenorphine while inpatient puts this patient at high risk for relapse and recurrent IE.Weeks later, the patient returns with symptoms of withdrawal after relapse heroin use 3 days prior. She reports not taking her amoxicillin. Echocardiography shows a 1×1 centimeter vegetation on her bioprosthetic aortic valve. Blood cultures grow methicillin-resistant Staphylococcus aureus. Cardiac Surgery determines she is not a surgical candidate given concerns about the success of repeat valve replacement in the setting of active IDU, refusal of buprenorphine, and antibiotic nonadherence. She receives medical management, however, remains bacteremic and refuses initiation of buprenorphine. One week later, she experiences a pulseless arrest and expires (Figure 1).Download figureDownload PowerPointFigure 1. Clinical timeline of events. AMA indicates against medical advice; and MAT, medication-assisted treatment.The decision to proceed with repeat valve replacement depends on the risk of the procedure itself and on the likelihood of postoperative success, which depends on adherence to postoperative antibiotics and management of comorbid conditions to maximize benefit and avoid harm. A 2015 Scientific Statement by the American Heart Association on IE in adults makes note that "it is reasonable to avoid surgery when possible in patients who are IDUs" due to subsequent risk of device infection with continued IDU (Class IIa).21 However, updated Clinical Practice Guidelines published in 2020, recommend "consultation with addiction medicine about long-term prognosis before repeat surgical intervention" (Class I).5 A recent national survey of cardiac surgeons demonstrated that although surgeons would operate at similar proportions for patients with native valve non-IDU-IE (63%) and IDU-IE engaged in methadone treatment (64.5%), only 26.4% would operate on patients with recurrent IDU-IE, compared with 93.1% of recurrent non-IDU-IE patients.22An individualized approach with aggressive treatment of both IE and SUD would therefore give patients the best opportunity to achieve optimal outcomes.23,24 Despite a multidisciplinary approach to address IE, SUD, mental health, and social needs, this patient ultimately did not receive MAT or other SUD treatment options. During her second hospitalization, she declined these resources and soon became too unstable for their initiation. Without MAT, adherence to antibiotic therapy and postoperative care would have been difficult and placed the patient at risk of not experiencing the benefits of this high-risk surgery. In this case, the inability to treat comorbid SUD directly impacted the treatment of her IE.CommentaryThe foundation of a root cause analysis is to ask "why" as often as possible. Doing so can identify different factors that contribute to poor health outcomes including environmental, organizational, cultural, staff performance, and process factors, among others (Figure 2).25Download figureDownload PowerPointFigure 2. Affinity diagram highlighting opportunities for improved care. IDU indicates injection drug use; and SUD, substance use disorder.We will elaborate on 3 "why" questions highlighting important considerations in this patient's care. We will propose corrective actions and potential next steps for institutions aiming to address such challenges (Table).Table. Action ItemsRoot cause factorsRoot cause detailsPotential corrective actionsOrganizational/resource allocationSuboptimal treatment of SUD while inpatientRoutine involvement of addiction medicine, psychiatry, and social work as part of multidisciplinary infective endocarditis teamFoster collaborative environment that prioritizes evaluation and management of substance use disorder, just as much as endocarditis itselfStaff performance/processIncomplete evaluation of decision-making capacityFormal evaluation of decision-making capacity for patients with history of SUDThorough investigation into reason for wanting to leave against medical adviceInsufficient resources/accessScarcity of community SUD resourcesExpand access to SUD resources through networks, collaborative, and consortiumsEncourage providers to obtain waivers to enable prescription and management of buprenorphine; educate providers on prescribing and managing naltrexoneIncentivize providers who care for and take on management of MATMAT indicates medication-assisted treatment; and SUD, substance use disorder.Why Is Treatment of the Patient's Substance Use Disorder Important?There has been an increased incidence of IDU-associated IE across the United States, comprising upwards of 22% of all IE cases. Although the success of treating IE is closely linked to SUD treatment, they are often treated as separate entities. In a review of patients hospitalized with IDU-associated IE from 2004 to 2014, only 42% of patients had mention of a SUD in their discharge summary, 11% of patients had a plan for initiation of MAT, and 0% of patients were prescribed naloxone.18 In addition, nearly half of the PWID who have IE do not receive addiction focused treatment during their index hospitalizations.18 This is in spite of literature suggesting that MAT can help prevent recurrent IDU and that targeted addiction teams can help reduce cost and length-of-stay.26,27One aspect that has made it difficult to provide adequate SUD treatment is the scarcity of buprenorphine providers, among other SUD treatment services. Locating a clinician who is skilled in the prescribing of buprenorphine can be quite challenging. Many patients are undertreated, and wait times for MAT can be up to 2 years in some areas.3,23,28,29 One way to combat this is to set up a "bridge clinic" where patients could follow-up post-discharge until another outpatient provider can be established.30 Another solution is for more clinicians (particularly in specialties such as cardiology, infectious disease, and cardiac surgery) to undergo waiver training for buprenorphine to allow for earlier initiation and continuity of care. A more recently proposed solution involves the deregulation of buprenorphine prescribing, also known as the "X Waiver", with hopes of increasing the number of eligible prescribers to assist in more patients receiving safe and appropriate SUD treatment.31Although increasing access to SUD treatment is important, it is just as imperative to educate medical professionals on the importance of SUD treatment in IDU-associated IE. This can be achieved through improved representation of addiction education within medicine, nursing, social work, and pharmacy school curricula. On a graduate medical education level, there have been national calls for the development of integrated infectious diseases/addiction medicine fellowships.32 Education must also revolve around addressing prejudices and biases that exist toward addiction. Much too often, health care providers have preconceived notions of patients with SUD, which are typically unfavorable and can negatively impact the relationship between patient and physician. In this case, directly addressing the patient's concerns, providing clinical psychotherapeutic support, and/or the prompt initiation of buprenorphine may have helped to deter an against medical advice discharge.Why Would Taking This Patient to Surgery Have the Potential for More Harm Than Benefit?Surgeons are frequently faced with difficult ethical questions when deciding whether or not to perform reoperative valve surgery in patients with IDU-associated ID. Reoperative valve surgery carries a substantial risk of morbidity and mortality, particularly in patients with IDU-associated IE.33 Cardiac surgery programs are strongly encouraged to publicly report their aortic valve surgery outcomes and failing to do so can impact reimbursement from the Center of Medicaid and Medicare Services. Such public reporting has previously been shown to promote risk-averse surgical decision-making, which can be detrimental to critically ill patients.34 This may also drive disparities in how surgeons approach reoperative valve surgery in patient with IDU-associated IE.22Decisions to refuse repeat valve surgery to PWID with recurrent IE have previously been supported by ethical arguments of medical futility, given the concern for continued IDU, and resource stewardship (justice).23,35,36 However, just as few providers would consider it ethically justifiable to cite medical futility and/or resource stewardship arguments to deny life-prolonging treatment to patients with poorly controlled end-stage renal disease or heart failure who do not adhere to disease management or dietary restrictions, these arguments should not be used for withholding surgical intervention from PWID with re-infected valves when the benefits of surgery have been determined to outweigh the harms.23,37 One approach could involve a period of sobriety and/or a contract between the surgeon and patient stating that if the patient continued IDU and re-infected, a second valve would not be offered.38 However, this approach risks being influenced by bias, with decisions about withholding surgery often based in frustration with PWID behaviors and moral judgements about IDU and the "worth" of the person, rather than based on medical and surgical appropriateness.23,37Why Should Multidisciplinary Teams Be a Part of Endocarditis Care?Multidisciplinary endocarditis teams improve compliance with antibiotic guidelines, decrease time to cardiac surgery, and dramatically reduce in-hospital mortality for patients with IE.39–41 As a result, such teams have become standard of care.42 The usual composition of a multidisciplinary endocarditis team includes cardiac surgeons, cardiologists, infectious diseases specialists, neurologists, pharmacists, and radiologists.39 However, psychiatrist and addiction specialists have yet to routinely take part in these multidisciplinary discussions. The updated 2020 Clinical Practice Guidelines for Valvular Heart Disease make a point to emphasize this gap and have recommended that addiction medicine play a role in the decision-making process when caring for patients who present with recurrent endocarditis from IDU (Class I).5For many years, the onus has been on surgeons to make the complex ethical decision about whether to offer surgery to endocarditis PWIDs because endocarditis is, ostensibly, the final common pathway of the patient's SUD. However, as this case highlights, it requires a comprehensive, multidisciplinary approach with investment from health care systems. The ethical obligation to provide care to this patient population does not and should not fall squarely on the shoulders of cardiac surgeons but rests with all medical providers and the hospitals and systems for which they work. Health care professionals have an obligation to continue to treat PWID with IE as we would other patients.37 We need new approaches to ethical decision-making and evidence-based guidelines that recognize the multifactorial etiologies of recurrent IE in PWID and promote novel solutions to improve care.23,24,29,43–45 Reframing the ethical debate with this in mind is required before this challenging disease can be successfully treated.The incorporation of a dedicated inpatient addiction consult service into our multidisciplinary endocarditis team would have been ideal for coordinating this patient's SUD treatment. Such a team, staffed by specialists and social workers trained in managing OUD, could have managed this patient's withdrawal symptoms, initiated MAT earlier, and facilitated referrals to an outpatient buprenorphine prescriber. All of these actions would have improved this patient's care and potentially prevented an adverse outcome.Learning PointsSubstance use treatment requires an urgency equal to that of endocarditis treatment.A standardized multidisciplinary approach to care is warranted, which should include early initiation of MAT.Increased advocacy to address treatment gaps in patients with endocarditis and SUD is needed.AcknowledgmentsDrs Yeow, El-Dalati, E.A. Jouney, Drs Firn, Deeb, and Konerman made substantial contributions to the conception and design of the work; drafting and revision of the article; and gave final approval of the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Disclosures None.FootnotesFor Disclosures, see page 1022.Correspondence to: Raymond Y. 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