Risk Management



Poor communication between providers delays GCA diagnosis

RYAN BUCSI, OMIC Senior Litigation Analyst

Allegation

Failure to diagnose and treat giant cell arteritis.

Disposition

Settled for $50,000 on behalf of OMIC insured. Codefendants later settled for $500,000.

An 85-year-old patient with polymyalgia rheumatica (PMR) was being treated with steroids by her internist. He tapered her off the steroids when her symptoms were controlled but restarted the drug at a low dose two weeks later when she experienced a headache. Two weeks after that, the internist suspected giant cell arteritis (GCA) due to diplopia. He provided two referrals: one to our insured ophthalmologist to evaluate the diplopia, and the second to a neurologist to initiate and manage high-dose steroids. The referral slip noting the history of PMR and steroid treatment never reached the ophthalmologist. However, the ophthalmologist’s technician documented that the patient was on steroids. The insured obtained a history of chronic headaches and new onset of intermittent vertical diplopia. He found a large left hypotropia as well as moderate macular degeneration and recorded uncorrected visual acuities of 20/60 OD and 20/40 OS. The insured discussed the possible causes of diplopia with the patient and recommended that she follow up with her internist and see a neurologist. The patient saw a neurologist, who diagnosed GCA, increased her dose of steroids, recommended hospitalization—which she refused—and referred her back to the ophthalmologist. The patient was seen by our insured five days later (two weeks after the initial visit) and reported that earlier in the day she experienced dramatic vision loss and headache. VA was hand motion OD and 20/400 OS. A dilated examination revealed inferior retinal ischemia indicating central retina artery occlusion with acute optic neuritis. The insured concurred with the diagnosis of GCA. He explained to the patient that her vision was unlikely to improve and advised her to follow up with her internist and neurologist for steroid management. He asked her to return in two weeks but she did not. Eventually, the patient ended up with bilateral blindness and required 24-hour care.

Analysis

OMIC’s defense experts had mixed opinions about the insured’s care. One felt management at the initial visit was appropriate since no circulatory issues were identified during the dilated exam. Others felt our insured could be criticized for not reading the note about the patient’s steroid use and eliciting her history of PMR, which is strongly associated with GCA. He was also criticized for not considering GCA given the patient’s age, headache, and diplopia. Furthermore, our experts pointed out that the insured did not take a sedimentation rate, CBC, CRP, or platelet or fibrinogen levels, nor was there a recommendation that these be obtained by the internist or neurologist. Additionally, the insured did not recommend a temporal artery biopsy. Our experts’ major issue with the insured’s care was his failure to communicate to the patient, her family, and other doctors involved in her care the high risk for vision loss and need for emergent intervention. However, the experts felt the internist and neurologist had greater exposure than the ophthalmologist. Fortunately, plaintiff counsel agreed that our insured’s liability was limited and a settlement of $50,000 was negotiated. The internist and neurologist later settled for a total of $500,000.

Risk management principles

This case highlights the importance of communication with other healthcare providers. The ophthalmologist, internist, and neurologist did not effectively communicate with each other and did a substandard job of coordinating this patient’s care. Two of the three physicians suspected GCA before serious vision loss occurred but did not share this crucial information in a timely manner with the ophthalmologist. The internist did not provide our insured with an adequate history about the PMR and suspected GCA, which could have assisted the insured in reaching the correct diagnosis and increasing her steroid dosage to treat the GCA. The ophthalmologist, moreover, missed an opportunity to intervene earlier by not reading his technician’s note about Prednisone use, exploring the reason the patient was on it, and making the association between PMR and GCA. The ophthalmologist was in the best position to know the risk with regard to potential loss of vision and the urgency of increasing the steroid dosage and obtaining a temporal artery biopsy. Furthermore, our insured’s documentation was inadequate. When the records were reviewed, our expert could not understand what the insured’s thought process was and if he passed his thoughts and opinions on to the internist and neurologist.

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