Healthcare Inspection – Diagnosis and Treatment of a Patient’s Adrenal Insufficiency at a Virginia VA Medical Center

OIG conducted a review to assess allegations of misdiagnosis of Addison’s disease and adverse outcomes resulting from long-term steroid treatment in a patient with multiple medical problems. We substantiated that the patient’s electronic health record problem list first reflected the patient had Addison’s disease in 2004 although laboratory tests did not support this diagnosis. The patient received steroid medications after developing signs and symptoms of adrenal insufficiency in 2004. Because steroid medication was the appropriate treatment option for adrenal insufficiency that was caused by either Addison’s disease or another disease process, the patient received appropriate care at the time the steroids were initially started. Between 2004 and 2006, VA providers were not able to assure routine follow-up of the patient’s condition due to irregular use of health care services. When the patient re-established routine care with a VA primary care provider in 2007, actions should have been taken to reassess the patient and confirm the adrenal disease-related diagnosis. Ultimately, a comprehensive evaluation of the patient’s medical history, co-occurring conditions, lab and imaging tests, and medication actions and interactions was completed in 2012 and an endocrinologist was able to wean the patient off chronic steroid therapy. We could not substantiate the allegation that the patient experienced adverse health events including avascular necrosis of the hip joints solely as a result of prolonged steroid treatment for adrenal insufficiency. The patient had a complex medical history, and we believe the most likely cause of the avascular necrosis and need for bilateral hip replacement was a combination of long-term steroid use and the various treatments used to manage his other comorbidities. We made one recommendation.