Disparities in Health Care: A case presentation

Julio Silvestre, MDFaculty: Akhila Reddy, MD

Case presentation38-year-old Hispanic gentleman with a history of a newly-diagnosed widely metastatic adenocarcinoma, spread to the lymph nodes, bilateral lungs, soft tissue, and bone.

Admitted on 12/4/12, complaining of 1 month history of back pain precipitated by exertion. For 1 week PTA, he was unable to walk.

Had urinary hesitancy. Consulted a chiropractor but pain worsened. Had saddle hypoesthesia, intermittent urinary retention and constipation.

Anxiety reported.

Consult to Neuro-oncology.

• Admission to Internal Medicine.

Case presentation• Outside MRI of the lumbar spine & pelvis Lytic lesions S2–S4.

• Neuro-oncology consult: Suspected cauda equina. Continue Dexamethasone, Radiation Oncology consult.

• Orthopedics consult – “Significant tumor burden to the sacrum as well as other multiple sites with a possible impending fracture to the proximal right femur.”

• Social worker – “Patient and spouse indicate that they feel anxious and overwhelmed.” Educated about economy parking, meals and KIWI.

Electronic Patient Needs Assessment (ePNA) - distress level of 8/10. Assisted with concerns about family and drafting a visa letter for the patient's father.

Hospital course2nd Day Radiation Oncology –

Palliative Radiation to the sacrum.

3rd Day Thoracentesis – Positive for malignant cells.

Abdominal wall biopsy - Metastatic poorly differentiated adenocarcinoma with focal signet ring cells.

4th Day Social work –

Application for emergency Medicaid.

Brother is coming to MD Anderson and has this information about father for application to US Visa.

6th Day Orthopedics –

?Percutaneous hip pinning under spinal anesthesia.

?IVC filter. Cleared for surgery.

SC Consult 12/13/12

• Pain in mid lower spine and radiates down to the RLE into the foot.

• Burning sensation in his posterior calf. “He did have a shock-like pain a month ago in his right buttock, but now he has a dull ache.”

• Was not able to hold enema in for more than a few seconds.

• Mild chest pain and has shortness of breath which was initially severe but has significantly improved following the thoracentesis earlier in the hospitalization.

• MDAS in 0/30.

• CAGE-AID is negative.

• Performance status: ECOG 3.

ESAS

Psychosocial history

• Married. Lives in Sheperd, TX with wife and 3 children: 9, 7 and 11 months old. One of his children has Lowe syndrome.

• UNDOCUMENTED, UNINSURED.

• Wife is a housewife, not working. Takes children to school everyday. Little family support.

• Has one brother in Houston, who is not very close.

• Patient works in construction company doing dry wells. Remote history of cigarette smoking approximately when he was in at age 11.

• Drinks beer a 6 pack a month. No drug abuse.

• Anxious about treatment and financial situation: “How are we going to pay the bills?”.

SC Consult 12/13/12 Past Medical History:Questionable history of hypertension and Hyperlipidemia.

Medications:1. Dexamethasone 4 mg intravenous every 6 hours.2. Heparin GGT.3. Hydralazine 10 mg intravenous every 6 hours as needed.4. Hydromorphone 2 mg intravenous every 2 hours as needed (14 mg utilized in the last 24 hours).5. Ketoralac 15 mg intravenous every 6 hours as needed.6. Metoprolol succinate 25 mg by mouth daily.7. Ondansetron 8 mg intravenous every 8 hours as needed.8. Pantoprazole 40 mg orally daily.9. Piperacillin and tazobactam 3.375 grams intravenous every 6 hours.10. Senna/docusate and Miralax

T: 36.8, HR: 134, RR: 20, BP: 154/87, Weight: 55 Kg. • Robust frame, NAD. ENT: Unremarkable.• Neck: Supple. • CV: RRR, S1 S2 normal, no murmurs, rubs or gallops.• Respiratory: Blunted breath sounds right hemithorax, ronchi.• Abdomen: Soft, not distended, not tender, BS positive.• Musculoskeletal: FROM, Muscle strength: 5/5. Mild pain on

ranging of the bilateral hip joints • Neurologic: A&Ox3. Quadriceps strength to left side is 4+/5.

Mild pain on palpation also to the right proximal thigh. DTR normal. Decreased pinprick and light touch sensation in the sacral area. Numbness to the inner aspect groin of the left side.

• No edema, no cyanosis or clubbing.

Physical examination

Labs:

139 99 13

3.6 25 0.73 <166

<> 36

12.3

LDH: 1K INR: 1.2

LFT:NL Alb: 3.9

12.3 302

Ancillary

Cancer Ag 125: 884

Spine MRI

Chest CT

Abdomen CT

Recommendations1. Pain – Hydromorphone PCA.

Agree with Dexamethasone.

2. Constipation –

Enemas

Continue Senna and Miralax.

3. Advance Care planning –

No Medical Power of Attorney, no Advance directives.

4. Psychosocial –

Expressive supportive counseling.

Hospital course13th Day Social worker –

Patient is a resident of San Jacinto County Texas. HE IS UNFUNDED. He is not eligible for state Medicaid, SSI, SSI Disability or the UTMDACC Patient Financial Assistance (PFA) Program due to his residency. Not eligible for medical care at the Harris County Hospital District.

Emergency Medicaid application

14th Day Palliative radiation finishes. Pulmonary for Thoracentesis pleural catheter.

15th Day Pulmonary embolism. Percutaneous pinning of pathologic right femoral neck fracture.

Hospital course17th Day Pulmonary – Thoracentesis for Dyspnea

Pleurx catheter placement.

18th Day Chemotherapy on Carboplatin and Pemetrexed.

23rd Day Hematochezia. Coumadin held.

27th Day GI – Colonoscopy - Sigmoid mass. Biopsy: Colitis ?XRT.

Social work – Faxing documents.

29th Day Social work Indigent program has been denied due to patient being over resources (value of his car and property)

32nd Day Right lower extremity edema. ?Compartment syndrome. Extensive VTE on Doppler.

Hospital course34th Day Social work – Family may appeal Denial.

“Patient expressed frustration that they are over allowable resources, stating „we don't have anything.‟“

“Discussed that patient/spouse are responsible for medical expenses incurred at MD Anderson.”

38th Day No compartment syndrome.

Extensive conversations with family: no further chemotherapy.

Referral to hospice.

40th Day Charity hospice referral.

Disparitiesin

Health Care:A nightmare

http://www.dol.gov/oasam/programs/history/herman/reports/futurework/report/pdf/ch1.pdf

Cancer in the US

Frist, W. H. (2005). "Overcoming Disparities In U.S. Health Care." Health Affairs 24(2): 445-451

Poverty Rates

Freeman, H. P. (2004). "Poverty, Culture, and Social Injustice: Determinants of Cancer Disparities." CA: A Cancer Journal for Clinicians 54(2): 72-77.

Uninsured

Freeman, H. P. (2004). "Poverty, Culture, and Social Injustice: Determinants of Cancer Disparities." CA: A Cancer Journal for Clinicians 54(2): 72-77.

Uninsured-Consequences• In 2002 more than half of African Americans, Hispanics,

and American Indians/Alaska Natives were poor or near-poor.

• More than 20 percent of African Americans and more than 30 percent of Hispanics were uninsured. Hispanics are the most likely of any racial and ethnic minority to be uninsured.

• Undocumented immigrants exceed 10 million, or 29% of the total US foreign-born population.

• Low SES is usually associated with poor access to care, riskier behavior, fewer community resources, and higher mortality.

Cancer in the PoorIn 1989, the ACS‟ “Cancer in the Poor: A Report to the Nation.”

- Lack access to quality health care and are more likely than others to die of cancer.

- Endure greater pain and suffering from cancer.- Face substantial obstacles to obtaining and using health

insurance and often do not seek needed care if they cannot pay for it.

- Must make extraordinary personal sacrifices to obtain and pay for health care.

- Cancer education and outreach efforts are insensitive and irrelevant to many poor people.

- Fatalism about cancer prevails among the poor and prevents them from gaining quality health care.

DuBard C, M. M. W. (2007). "Trends in emergency medicaid expenditures for recent and undocumented immigrants." JAMA 297(10): 1085-1092.

Complex problem- Emergency Medicaid in North Carolina - 93%of Applications

– Hispanic.

- 39 of 129 millons of US dollars in Texas.

- More likely to be treated at late stages and to die from cancer.

- Late referrals were the family belief that palliative care shortens the patient‟s life, insufficient advance discussion about palliative care, and lack of preparation for the changes in the. patient‟s condition.

- Physicians were found to more frequently have negative perceptions of minorities and persons of low or middle socioeconomic status than of whites and persons of high socioeconomic status.

Francoeur, R. B., R. Payne, et al. (2007). "Palliative care in the inner city." Cancer 109(S2): 425-434.

Shavers, V. L. and M. L. Brown (2002). "Racial and Ethnic Disparities in the Receipt of Cancer Treatment."

Journal of the National Cancer Institute 94(5): 334-357.

Greiner, K. A., S. Perera, et al. (2003). "Hospice Usage by Minorities in the Last Year of Life: Results from the National Mortality Followback Survey." J Am Ger Soc 51(7): 970-978.

Fourscore and seven years ago our fathers

brought forth upon this continent a new nation,

conceived in Liberty, and dedicated to the proposition

that all men are created equal.… It is for

us, the living…to be dedicated here to the unfinished

work that they have thus far so nobly carried

on.

—Abraham Lincoln, 1863