Inspector General report rips Phoenix VA urology care

A scathing report on urology care at the Department of Veterans Affairs hospital in Phoenix says some sick veterans died awaiting care and hundreds were medically sidetracked or neglected because of short-staffing and mismanagement.

The Office of Inspector General report says 45 percent of patients with bladder, prostate and urinary-tract issues received delayed care, or no care at all, during the last two years, even after patient wait times became a national scandal. The report also says investigators cannot yet calculate the damage suffered because medical records are messed up and missing.

The report described 10 cases where patients' treatment or diagnosis was so delayed it "may have affected their clinical outcomes," and added, "Such delays placed patients at unnecessary risk." In half of those 10 cases, the patients died.

Beginning in 2013, the Urology Services clinic at Carl T. Hayden VA Medical Center became understaffed and overbooked due to an exodus of doctors and nurse practitioners. The report says backlogs were exacerbated by a failure of hospital administrators to address the crisis. As a result, veterans with cancer and other serious illnesses could not get evaluated and treated. The system was so dysfunctional, according to the OIG, that urology appointments for hundreds of veterans were simply canceled without notice and never rescheduled.

Deaths at Phoenix VA hospital may be tied to delayed care

The report says some employees pleaded with administrators to address the problem in 2013, to no avail. An email to Sharon Helman, then director of the Phoenix VA Health Care System, described conditions:

"We as clerks' (sic) are dealing with the frustrations of the veterans daily and we don't have any answers for them. We can't make appointments for them ... This has been going on now for months and still no guidance or answers. We are getting our heads handed to us by the patients. How much are we supposed to endure ... PLEASE HELP. We are leaving our vets in limbo."

Helman was fired last year. She has not responded to interview requests.

A breakdown in the urology clinic was among the most alarming criticisms made by Phoenix VA whistleblowers two years ago when they sought to expose delays in care and a corrupt VA culture.

During fiscal 2013-14, the entire urology staff — three physicians and three nurse practitioners — quit or went on leave. For a while, only one part-time urologist was working, and no nurse practitioners. Appointments were canceled, often without notice to patients. Some veterans ostensibly were referred to private care, but even many of those appointments did not occur due to bureaucratic breakdowns or negligence.

Inspectors ripped administrators at the Carl T. Hayden VA Medical Center for not addressing the crisis as it evolved. But they did not explain why the problem was not solved, or why so many urology staffers quit.

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Sam Foote, a retired Phoenix VA physician whose complaints to the OIG and Congress launched a nationwide review of care for veterans, said administrators refused to authorize outside appointments because of budget issues. Foote said once Urology Services was overwhelmed, he and others pleaded for approval to send patients to non-VA doctors, But hospital administrators refused.

"They (OIG investigators) didn't document why this happened," Foote said. "They missed the whole boat. ... The report says administrators didn't have a plan. Well, yes, they did have a plan — to not spend a dime on fee-based care."

Foote first alerted OIG investigators of the crisis in a 2013 letter that said administrators were using bully tactics to carry out an intentional purge of the urology staff. In an interview Thursday, Foote said he was dumbfounded that the OIG took so long to investigate, given the consequences for patients. He also criticized inspectors for failing to explain what caused the staffing shortage.

Republican Arizona Sens. Jeff Flake and John McCain issued a joint statement in reaction to the report, calling the findings "beyond unacceptable. ... Congress has given the VA the tools to tackle these backlogs," they added, "and it’s well past time that the agency put them to full use.”

Rep. Kyrsten Sinema, D-Phoenix, described the report as "appalling" and the VA's failure to care for veterans as an "atrocity."

The OIG report says that Phoenix administrators finally authorized outside appointments in May 2014, but even then the process was stalled by "complicated administrative processes." In September 2014, the report says, more than 3,000 urology patients were listed as "lost to follow-up" because their care status was unclear.

The OIG report notes that in addition to medical consequences, patients who could not get care "also likely experienced frustration, confusion and often fear." It describes one incident where a Holbrook veteran with prostate cancer was driven nearly 200 miles by his wife for an appointment, unaware that it had been canceled.  "Of course, they were not notified," says a clerk's email to the scheduling supervisor. "The veteran's wife spent the remainder of her time holding back tears..."

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The OIG report does not estimate the number of deaths that might have been prevented or lives prolonged by timely care. It says 1,484 patients experienced significant delays, and listed 10 who were placed at "unnecessary risk for adverse outcomes." At least half of those died.

Among the examples:

• A veteran with a cancer history whose checkup was canceled and not rescheduled. Relapse was discovered when he visited a primary care physician 10 months later. He died four months after that.
• A patient who was referred for urology evaluation due to symptoms did not get an appointment for three months. It was canceled and rescheduled a month later. That appointment also was canceled. After more delays, the veteran finally received a biopsy and was diagnosed with metastatic cancer of the prostate. He began radiation therapy about 18 months after the initial referral.
• In June 2013 a patient in his 70s began treatment for an enlarged prostate. He experienced blood clots in his urine eight months later and his daughter requested care, but was told repeatedly to "be patient, there are still no providers." An appointment finally was scheduled with a private physician in May 2014. VA records incorrectly showed the man as a no-show. In fact, he saw the outside urologist and needed a procedure requiring further authorization. The veteran died 10 days later.  

OIG inspectors found that the Phoenix VA had incomplete medical records on 759 urology patients, with potentially adverse implications for diagnoses and treatment. That breakdown primarily involves patients who were referred for outside care. Investigators are still seeking documentation, the report says, trying to determine patient needs and whether missing diagnoses, lab tests and referrals resulted in bad outcomes.

The inspector general issued recommendations for Phoenix VA administrators to provide timely care, improve record-keeping and review cases that resulted in adverse outcomes for possible disclosure to patients and families. The report says Phoenix VA administrators concurred with the findings and have developed acceptable improvement plans.

The VA did not respond late Thursday to a request for information on current staffing of Urology Services.