The Phoenix VA report by the VA’s Office of Inspector General has been released, and it’s a scathing indictment of the treatment, practices and real harm done to veterans by the Phoenix VA health care system.
While the OIG found no evidence to directly substantiate the allegations of 40 deaths of veterans who were awaiting treatment in Phoenix (it says it was not provided a list of the 40 patients by the whistleblower), it did examine 3,409 veteran patients — including the 40 veterans who died while on the hospital’s electronic waiting list — and was able to link 20 veterans who died to substandard care at the Phoenix VA.
The OIG report, which you can download in its entirety here, discussed 45 cases of veterans reflecting “unacceptable and troubling lapses in follow-up, coordination, quality, and continuity of care.” We present each of the 45 cases to you over these next three screens.
Have you experienced similar problems during your visits to VA hospitals or clinics?
A man in his late 60s had a history of homelessness, diabetes, head injury, hepatitis, and low back pain. He had been seen at multiple VA health care facilities across the United States during 2011–2013. He presented to the PVAHCS ED with a minor injury and requested a place to stay. He was found to have markedly elevated blood glucose (477 milligrams/deciliter [mg/dl]) and was treated with insulin and intravenous fluids.
The patient stated that he did not want to take insulin, an injectable medication, and was therefore started on metformin, an oral blood sugar-lowering medication. The ED physician requested that he have a follow-up appointment with Primary Care within 24 hours. The patient was not given an appointment to be seen in Primary Care; multiple visits to non-VA EDs ensued, and he was hospitalized at two different non-VA hospitals. A death certificate obtained from the State of Arizona indicates the patient died at a local non-VA hospital 8 weeks after the PVAHCS ED visit.
Given the patient’s homelessness and uncontrolled diabetes, hospitalization would have been optimal. In that he was not admitted, a more urgent scheduling effort than a “Schedule an Appointment” consultation (consult) was required.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his late 60s had a history of homelessness, hypertension, diabetes, cirrhosis, congestive heart failure, and emphysema. He had been hospitalized at a New England VA Medical Center (VAMC) and at a Texas VAMC. He presented to the PVAHCS ED with 1 week of generalized weakness and diarrhea. He had recently moved to the Phoenix area from New England.
A Schedule an Appointment consult for a new patient primary care appointment was placed on the day of the ED visit and again 2 days later. After an additional 2 days, the patient was hospitalized at a non-VA hospital for abdominal swelling and weakness. Eleven weeks after that admission, he was hospitalized at a different non-VA hospital for hepatic encephalopathy.
More than 3 months after the patient’s death, PVAHCS staff attempted to call the patient to schedule a primary care appointment.
Although unlikely to change the overall outcome for this patient with severe liver disease and other medical problems, primary care management could have improved symptom control and assisted with specialty care coordination.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his mid-60s had a history of diabetes, hypertension, hyperlipidemia, cigarette smoking, and post-traumatic stress disorder (PTSD). He transferred his care from a Midwest VAMC and registered for care at PVAHCS. The patient’s family reported that he was having flu-like symptoms and that they attempted to get him an appointment at PVAHCS several times after registration without success.
Four months after registering at PVAHCS, the patient sought care for flu-like symptoms and shortness of breath at a non-VA medical facility, where he was diagnosed and treated for pneumonia. A computerized tomography (CT) scan performed at that facility revealed a large left pulmonary mass and enlarged lymph nodes suggesting “local spread of malignancy.” The patient was advised to follow up with his PCP to have a positron emission tomography (PET) scan.
Two weeks later, the patient called PVAHCS and explained that he had been recently discharged from a local hospital and needed “another test.” He was advised to “walk-in,” which he did, and was seen that same day. On examination, a provider noted an “enlarged, firm lymph node in the supraclavicular [above the collarbone] area on the left side” and ordered a CT scan of the chest. The CT scan, completed 1 month later, revealed a large left hilar mass and bilateral mediastinal and hilar adenopathy. Four weeks after the CT scan, the patient underwent “diagnostic bronchoscopy with endobronchial biopsy & lavage + axillary needle biopsy.” A diagnosis of lung cancer was made, and a PET scan confirmed widely metastatic disease. Arrangements were made to enroll the patient in hospice. The EHR contained no information indicating where the patient died, or whether hospice care was actually provided prior to his death.
There are two concerns in this case. First, the patient never received a primary care appointment as requested when he registered at PVAHCS, although this does not mean that the patient’s lung cancer would have been detected sooner. The second concern is that once malignancy was suspected, at least 9 weeks elapsed before a definitive diagnostic procedure was performed.
Given the size and location of the tumor at the time of diagnosis, the delay in care for this patient was unlikely to have had a negative effect on his overall prognosis. However, his care might have been improved if palliative care had been implemented sooner.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his late 70s had a history of hypertension, chronic alcohol abuse, and obesity. In late 2011, the patient was seen in the PVAHCS ED for “bronchitis vs early pneumonia.” He was not seen again at PVAHCS until the summer of 2013, when he presented to the PVAHCS ED with lower extremity edema. He was found to have deep vein thrombosis, was briefly hospitalized, and discharged home with anticoagulant medications. At the time, a Schedule an Appointment consult was entered for an urgent Primary Care appointment.
The patient was seen again in the ED 2 weeks later for back pain. The treating provider’s note included the statement, “Follow up with assigned clinic or primary care physician within 72 hrs [hours] from this emergency room visit today.” At that time the patient was noted to be anemic (hematocrit 28 percent; normal is greater than 37).
The patient presented again to the ED 1 month later with a nosebleed, and a nasal balloon was placed. He was seen in the ED 2 days later for removal of the nasal balloon, and at that time, another Schedule an Appointment consult was entered for Primary Care; an appointment “Within 1 week” was requested.
One month later, the patient presented again to the PVAHCS ED with weakness and decreased urine output, and he was admitted to the hospital. He was noted to have a history of uncontrolled hypertension and was considered to be volume depleted. Laboratory testing revealed acute renal injury, hypoalbuminemia (low blood albumin), and nephrotic range proteinuria (large amount of protein in the urine). Following a 1-week hospitalization, he was discharged to a skilled nursing facility for rehabilitation. He died 5 weeks later.
This patient had delayed Primary Care follow-up after several ED visits. With anticoagulation, anemia, hypertension, and kidney disease, earlier primary care management could have expedited treatment of anemia and hypertension and facilitated coordination of his specialty care.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his mid-50s had a history of pancreatitis, three cerebrovascular accidents (strokes), hypertension, and polysubstance abuse. He moved to the Phoenix area from the East Coast in early 2014. He had received treatment at another VAMC as well as from non-VA providers prior to his relocation to Phoenix.
The patient presented to the PVAHCS ED with abdominal pain, was given medications for nausea and pain, instructed to follow up with a PCP “within 72 hours,” and discharged home. According to an entry on the Schedule an Appointment consult record, the consult was canceled the next day and a note was put in the EHR documents that a message was left for the patient to call and schedule an appointment.
Ten days later the patient again presented to the ED because of persistent pain and he had run out of pain medication. According to the nursing triage note, “Pt [The patient] states he forgot to take his lisinopril [a blood pressure lowering medication] today.” His blood pressure was 209/107 millimeters of mercury (mm Hg). He requested methadone and Percocet [oxycodone and acetaminophen] but was prescribed only a limited supply of oxycodone and a medication for nausea. The plan outlined by the ED physician stated that the patient should follow up with Primary Care within 2 days. The patient died 12 days later at a non-VA hospital. The cause of death given on the death certificate was “multiple prescription medication intoxication.”
Despite this patient’s need for blood pressure monitoring and treatment, as well as management of other chronic conditions, he never received an appointment with Primary Care.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his mid-50s presented to the PVAHCS ED with shortness of breath, excessive sweating, thirst, and numbness in both hands. His blood glucose level was markedly elevated (516 mg/dl), and he was prescribed metformin and advised to see his PCP within 1 week. He was not seen by a PCP, ran out of medication, and returned to the ED 1 month later with symptoms of uncontrolled diabetes. His medications were renewed, and a diabetes teaching appointment was made. Twelve weeks later he was seen in Primary Care.
This symptomatic patient with newly diagnosed diabetes was not scheduled to see a PCP for almost 4 months after an ED visit at which significant symptoms and laboratory abnormalities were noted.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his late 60s was evaluated in the PVAHCS ED for a subcutaneous cyst on his back and treated with an antibiotic. Eight months later, he was seen in the ED for chest pain. His blood pressure was 180/124 mm Hg, and an electrocardiogram showed an abnormality. After his hypertension was treated and testing showed no myocardial infarction, he was discharged with blood pressure medication and advised to follow up with a PCP within 2 weeks. No Cardiology appointment was made, but a Primary Care appointment was scheduled for 7 months later. A PVAHCS physician who became aware of this patient’s situation evaluated him 5 months after the ED visit and entered a referral to cardiology. The patient subsequently underwent coronary artery bypass surgery.
Although this patient had a favorable outcome, the delay in scheduling follow-up care after an ED visit exposed him to unnecessary risk.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his early 40s presented to the PVAHCS ED concerned that he might have melanoma, a potentially fatal form of skin cancer.
The ED provider note described skin lesions on each arm and the left ankle, “present for about a year, recently getting larger, changing shape and darker…could be melanoma, needs further evaluation.”
A referral to general surgery was requested by the ED provider, but this consultation was canceled by a general surgeon the next day with a notation that the patient should be evaluated and treated by dermatology. Approximately 10 months later, the patient was evaluated in Primary Care, and a consult was placed to Dermatology. The lesions were determined to be benign.
Failure of basic consult management and coordination of care could have led to serious consequences had these lesions ultimately been diagnosed as melanoma.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his 60s was treated in the past at PVAHCS for substance abuse, depression, and PTSD. After 15 years, he presented to the PVAHCS Mental Health Clinic, and a psychiatrist wrote that he had PTSD, depression, alcohol abuse, and multiple problems with his “primary support system.” At that visit, the patient’s blood pressure was 191/102 mm Hg and a repeat measurement was 175/102 mm Hg; a Schedule an Appointment consult for routine Primary Care follow-up was entered. One week later the patient was added to the EWL for a PCP appointment, and an appointment was made for 15 weeks after the Mental Health Clinic visit. The patient was seen again in the Mental Health Clinic 5 weeks after the initial visit, but his blood pressure was not recorded.
This patient’s hypertension warranted expeditious evaluation and treatment, which did not occur.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his 40s had a history of hypertension, traumatic brain injury, and alcohol abuse. He reported to the OIG Hotline that he called PVAHCS for an appointment to have his blood pressure checked and was told that an appointment would not be available for 6 months. He stated that 3 months after calling PVAHCS, he awoke with vertigo, nausea, and slurred speech. These symptoms resolved within a day, and he did not seek medical attention for them. After an additional 2 months, he was in an all-terrain vehicle accident and began having more frequent symptoms of slurred speech and dizziness.
When he was seen for his scheduled Primary Care appointment, his blood pressure was 163/107 mm Hg, and he was started on antihypertensive medications, counseled on alcohol use, and asked to follow up in 2 weeks. However, 1 week later he returned to the ED complaining of stuttering and slurred speech, and brain imaging was performed that revealed a large tumor. He subsequently underwent craniotomy and chemoradiation with no apparent recurrence of tumor.
This patient waited 6 months for a PCP appointment, during which time symptoms occurred that were attributed by the patient to hypertension. Although timely Primary Care management might have led to an earlier diagnosis of the patient’s brain tumor, his overall prognosis was probably unchanged.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his early 60s had a history of alcohol abuse and untreated hypertension. At the end of 2013, he presented to the Phoenix ED complaining of 2 weeks of shortness of breath. He was admitted overnight, diagnosed with “decompensated heart failure,” and scheduled for an outpatient echocardiogram. A Schedule an Appointment consult was placed for Primary Care. The echocardiogram was performed 3 weeks later.
He returned to the ED after another 3 weeks with extreme shortness of breath and vomiting, was admitted to the hospital, and soon transferred to the Intensive Care Unit. The result of the recent echocardiogram was not readily available because the interpretation had not yet been entered into the EHR.
After evaluation by cardiology, he was transferred emergently to a non-VA hospital where a defibrillator and pacemaker were placed. The EHR reveals that on the date of that transfer, the echocardiogram was interpreted as showing severely decreased cardiac function (left ventricular ejection fraction, 10 percent).
The Schedule an Appointment consult was closed, and the patient was placed on the EWL with a comment stating that the “wait time is approximately 143 days for a new patient appointment.”
This patient had severely impaired heart function identified by echocardiography. Prompt medical management might have prevented his subsequent deterioration.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his 70s was found to have an elevated prostate-specific antigen (PSA) and was referred by a PCP to the Urology Service. However, the consult was amended as “needs another psa.” A Urology appointment was scheduled for 3 months later, but this appointment was canceled by the Urology Clinic 1 week before the scheduled date because “provider not available”; the appointment was not rescheduled.
The PCP entered a referral for non-VA urology care 4 months after the original request, but this was denied on the basis that “the facility provides this service.” After an additional 4 months, the facility closed the Urology Service consult request, indicating “no longer accepting consults.” A request for non-VA urology care was again submitted, and the patient was seen by a non-VA urologist more than 11 months after the initial request. Prostate biopsy revealed prostate cancer.
This patient had a prolonged delay between the time his abnormal blood test was noted and a diagnosis was made.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his late 60s had an extensive cardiac history, including a myocardial infarction and placement of multiple coronary artery stents at non-VA facilities. After experiencing financial difficulties and unable to afford his medications, he was admitted to PVAHCS after presenting to the ED complaining of palpitations. Tests revealed no new abnormalities, and he had marked symptomatic improvement after medications were resumed.
During his hospitalization, an outpatient cardiology appointment was scheduled, but that appointment was canceled because “provider sick.” The appointment was rescheduled for the following month, but that appointment was canceled due to a “change in profile.” The consult was ultimately discontinued as “too old.”
Four months after his initial ED presentation, during a routine Primary Care appointment, another Cardiology Service consult was entered. However, the consult was discontinued with the notation “cardiac work-up negative, symptoms due to non-compliance.”
One month later, the patient presented to the ED with chest pain and palpitations and was admitted to the hospital. Another Cardiology Service consult was requested and the patient was seen as an outpatient the following month.
This patient with significant cardiac disease experienced repeated delays in establishing follow-up care with Cardiology. Although no negative clinical consequences are certain, appropriate cardiology care may have prevented re-hospitalization.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his 60s was found to have a nodular prostate. This finding prompted his PCP to place a referral to the PVAHCS Urology Service. An appointment was made for 3 months later, and the patient was seen and referred to an outside facility for a prostate biopsy.
Approximately 6 weeks later, after the biopsy was completed, the patient delivered a pathology report describing prostate cancer to the PVAHCS Urology Clinic, and a VA urologist called the patient to inform him that surgery would be arranged at a non-VA hospital.
In a complaint received by the OIG Hotline, the patient described a frustrating group of events over the next 2 months in which PVAHCS allegedly had no record of the non-VA referral for the procedure, the VA urologist who called the patient left PVAHCS, outside pathology and/or laboratory reports were misplaced, and multiple messages were not returned from the Patient Advocate’s office. In mid-November, the Patient Advocate’s office called the patient to state he had been approved for the outside surgical procedure and four follow-up visits. Eight months after the initial referral to Urology, the patient had an uneventful surgery.
This patient with biopsy-proven prostate cancer experienced repeated scheduling delays and poor coordination of care with non-VA providers.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his late 50s was seen in the PVAHCS ED for toe pain. Because of an elevated blood glucose level (206 mg/dl), he was considered to possibly have a new diagnosis of diabetes. He was subsequently seen in the Ambulatory Clinic and received foot care.
The patient was seen in Primary Care 3 months after the ED visit and hospitalized after he was found to have markedly elevated blood glucose level (739 mg/dl). The patient reported multiple symptoms consistent with uncontrolled diabetes, including weight loss, excessive urination, and excessive drinking. He was discharged from the hospital on insulin and metformin (an oral blood sugar-lowering medication).
The elapsed time between the patient’s ED visit and his initial appointment to be seen in Primary Care was excessive. Had the patient been scheduled more timely to be seen in Primary Care, it is likely that medications, education, and risk-appropriate screenings could have prevented his later inpatient admission.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014