By Syed Aman Ali
Medical Student, Jinnah Sindh Medical University, Karachi. Pakistan
Amin H. Karim MD, Houston, Texas
A condition that, once diagnosed in a young person, can be treated conservatively with diet and rest, can end up being treated expensively in a milieu where defensive medicine and financial incentive join together.
The case below is an example.
Case Presentation
A 20-year-old male student presented to the clinic with a 1-week history of abdominal pain and jaundice. He described the abdominal pain as a heaviness localized to the upper right quadrant, rating it 8 out of 10 on the pain scale. The patient also experienced mild fever, vomiting, and a headache. Patient later noticed jaundice, evidenced by icteric eyes and yellowing of the skin. He also reported dark urine and pale stools. He had recently traveled from Pakistan to the United States and went on a cruise approximately 2 weeks prior to the onset of symptoms.
On physical examination, the patient appeared generally well but jaundiced. Examination of the abdomen revealed tenderness in the upper right quadrant but no guarding and an enlarged liver. Patient was advised bed rest and symptomatic treatment till he felt better and was sent home.
Lab results were returned they showed that Hep A antibody was found to be reactive while Hep B and Hep C were non- reactive. Patient had a high total bilirubin of 12.8 mg/dl and alkaline phosphatase was raised to 182 U/L. AST was raised to 4317 U/L and ALT was raised to 5340 U/L. Patient had an increased hemoglobin 17.8g/dl and hematocrit 55.9%. The plan from our end continued to be conservative and symptomatic.
At the insistence of parents, patient saw a gastroenterologist for a second opinion and was immediately sent to the emergency room where he was admitted to the hospital for three days. A second gastroenterologist was called upon to see the patient. All of the lab reports were repeated and more tests were done including Epstein Barr virus test, cytomegalovirus test, thyroid panel. Patient had an ultrasound of the abdomen showing normal results an abdominal CAT scan showing normal result to be followed by an MRI of the abdomen which was also normal. The rationale for doing all three tests with a low pre-test probability of finding anything of significance was not known, Liver function tests were repeated on a daily basis. Liver biopsy was contemplated but not done. Family was reassured by providers that all is being done to make sure the condition does not become worse and that no “other conditions” are being missed!
In summary, the overall cost for the patient’s treatment, considering all expenses, ranged from $20,000 to $24,000. This cost reflects the comprehensive management of a benign condition easily treated with supportive care.
Discussion
Hepatitis A is an acute viral infection caused by the Hepatitis A virus (HAV), transmitted primarily through contaminated food or water. This positive-sense, single-stranded RNA virus, belonging to the Picornaviridae family, primarily affects the liver. It is a significant global health issue, especially in areas with poor sanitation. Typical symptoms include jaundice, fever, abdominal pain, and fatigue. While often self-limiting, Hepatitis A can lead to serious complications in some cases.
Complications and Variants
- Cholestatic Hepatitis A: Characterized by prolonged jaundice and impaired bile excretion, leading to darker urine and pale stools. Recovery is often longer and more intense.
- Prolonged Hepatitis A: Symptoms such as fatigue and jaundice extend beyond the usual acute phase, requiring extended care.
- Relapsing Hepatitis A: Involves periods of improvement followed by recurring symptoms like jaundice and abdominal pain, complicating the clinical course.
The chances of the above complications not withstanding, the condition in young people is benign and self limiting with no sequalae, in fact long term resistance to repeat infection
An important factor is to enhance the protocols for diagnosis and therapy. Better resource management and lower total costs can be achieved by establishing standardized care standards that prioritize evidence-based, economical therapies and simplify diagnostic tests to prevent redundancy. Improving the infrastructure for healthcare is also essential. By investing in sanitation and hygiene improvements in high-risk areas, as well as expanding access to early treatment and preventive care through community health centers and mobile clinics, outbreaks can be avoided and the financial strain on the healthcare system can be minimized.
Lastly, encouraging innovation and research can lead to advancements in prevention and treatment. Encouraging research into new, cost-effective management strategies and adopting best practices based on research findings will contribute to better healthcare outcomes. By implementing these strategies into practice, we can improve patient care while lowering costs in a more effective and efficient healthcare system.
Conclusion
In conclusion, this case study reveals a significant and somewhat ironic truth: treating Hepatitis A, a condition that often resolves on its own with minimal intervention, can still come with a hefty price tag of $20,000 to $24,000 in a milieu of defensive cum financially incentivized medical care. To address this, we should focus on preventive measures like vaccination and improved sanitation, which can help reduce both the incidence of Hepatitis A and the associated treatment costs. Additionally, refining diagnostic and treatment practices, investing in better healthcare infrastructure, and encouraging innovation in care strategies can lead to more efficient use of resources and reduced costs. By making these changes, we can enhance patient care and alleviate the financial strain on the healthcare system.
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