Download MD Training manual * module 1b case triage and tiers

MD TRAINING MANUAL –
MODULE 1B CASE TRIAGE
AND TIERS
January 2016
Best Doctors
MD TRAINING MANUAL – MODULE 1B CASE
TRIAGE AND TIERS
Table of Contents
Introduction and Rationale ......................................................................... 2
Objectives ................................................................................................... 3
Chapter 1: Service Tiers .............................................................................. 4
Chapter 2: Calling the member.................................................................... 7
Chapter 3: Deliverables for each Tier .......................................................... 9
Appendix A: Vignette Guidelines ............................................................... 10
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TRIAGE AND TIERS
Introduction and Rationale
As you learned from Module 1a, Best Doctors offers a variety of services to best
meet a member’s needs. In some instances, a case will be triaged to a specific
service line (e.g. InterConsultation) before your involvement. The MA, the Lead MD
or other operational team members involved in the case, may do this. In these
instances you should always look at the totality of information provided and
consider whether a different service line would provide the member with the
information they need in a more efficient way (e.g. a less intensive service line).
For some cases, you may be asked to triage cases at the pre-intake stage. This
will require reviewing a pre-intake form completed by an MA. As much as possible
these will be organized by specialty (e.g. GI, ID, Cardiology, Oncology) so that
physicians can select those they are best able to support.
In other cases you make actually do an intake and triage while on the telephone
with the member.
In all cases, you should triage the case to the tier that tis most efficient. Efficiency
in this context means choosing the service line that is able to meet the
member’s needs, with high quality, in the minimum amount of time. In
recognizing that two key areas that impact member satisfaction are the quality of
what we deliver and the timeliness, you should also choose the most streamlined
tier that can meet the member’s needs. The greatest drivers of extended case
timelines are the collection of extensive medical records and the integration of
these records into detailed summaries. Therefore, service lines that utilize no
records or only focused records, are generally more efficient.
This module will guide you through general service tiers, provide guidance with
regard to triage, and provide guidance as to how to perform an intake/triage call.
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TRIAGE AND TIERS
Objectives
At the end of this manual, you will:





Understand the rationale behind MD Triage
Understand the different service tiers
Understand the requirements and deliverables for each tier
Be able to choose between the different tiers
Be able to call a member to perform an Intake/Triage
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TRIAGE AND TIERS
Chapter 1: Service Tiers
An outline of service tiers are below and shown in Figure 1. Please note that
services at Best Doctors change dynamically as needed to better serve our
members and sometimes based on specific needs from large clients. So, when you
start working the names of services (e.g. Tier 1 or Tier 2) may change and
elements of Tiers (e.g. how many records or questions) may also change. You will
be informed and should always ask your Lead if uncertain.
As you review the tiers below please note that with each subsequent tier that there
is increasing resource intensity, complexity of workflow, and record collection. This
leads to longer timelines in general. Therefore the lowest tier that can meet the
member’s needs should be selected.
Service Tiers

Tier 1—Real-time Clinical Information
o The Associate Physician provides general information to answer a member’s
query without providing any specific management recommendations
o The AP writes a brief summary of the discussion which is furnished to the member and
also kept for internal records/auditing
o Whenever possible pre-approved educational materials are sent to the member
o If applicable (and available) you can suggest a Find Best Doctor (FBD) which identify
local specialists that the member can see in person

Tier 2—Expert Review Without Records
o The AP/MA creates a clinical vignette from the intake call.
o No medical record collection required.
o Expert input is obtained on 3-5 questions in the vignette, and specific
recommendations can be provided
o No UPW/BDRS
o No report discussion (RD)

Tier 3—Expert Review With Focused Records
o The AP/MA creates a clinical vignette from the intake call and directs MRC
o Up to 3 records (labs, single imaging study, 1-2 office notes) are collected
o Defaults to member MRC (specialist in records collection)
o Vignette and primary records are furnished to the expert
o Expert input is obtained on 3-5 questions in the vignette, and specific
recommendations can be provided
o No UPW/BDRS
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MD TRAINING MANUAL – MODULE 1B CASE
TRIAGE AND TIERS
RD with MA

Tier 3R— Expert Review With Focused Records Including Primary Imaging
o The AP/MA creates a brief clinical vignette from the intake call
o Defaults to member MRC (imaging and original report required)
o 2 questions posed:
 Please provide your interpretation of the imaging
 Any additional imaging recommended?
o Radiology report furnished to the member.
o No UPW, BDRS
o No RD

Tier 4— Expert Review With Extended Focused Records
o The AP/MA performs an intake and creates a clinical vignette
o More extensive records, (up to 4 imaging studies and up to 3 sets of office notes), are
collected
o Clinical vignette and primary records are furnished to the expert
o Expert input is obtained on 4-7 questions in the form of a Best Doctors Report (BDR)
which is sent ot the member
o +/- UPW, no BDRS
o MD or MA RD

Tier 5—Formerly known as InterConsultation (See Module 2 – MD Intake)
o The AP performs an intake and completes the intake template
o The AP directs MRC with regard to record collection
o The AP provides extensive input with regards to expert selection
o Extensive records are collected
o After record review a formal Clinical summary (CS) is created by the AP
o CS and imaging are furnished to the expert
o Expert input is obtained on 6-12 questions
o +UPW, + BDRS
o MD RD
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Figure 1 – Service Tiers
MEC +/- Clinical Support AP/MA Calls Member
Schedules with AP/MA with
Specialty Matching
Member
Ini ates
Service
Specialty-matched MD
Determines Op mal Service Tier
No MRC
Tier 1
Real- me
Clinical
Informa on
Internal Metrics
Summary of
Discussion and
Educa onal
Materials to
Member
Tier 2
Expert
Review based
on Vigne e
Clinical
Vigne e with
3-5 ques ons,
Case approval
Increasing complexity
MRC
Tier 3
Expert Review based on
Vigne e and Limited
Records
Tier 3R
Radiology Review based
on brief vigne e and
imaging
Clinical Vigne e
with 2-5 ques ons,
Records for
collec on (≤3), Case
approval +/- UPW
MA RD for T3
Tier 4
Expert Review
based on Vigne e
and Extended
Records
Tier 5
Expert Review based
on Formal Case
Summary and
Extended Records
Clinical Vigne e with
4-7 ques ons,
Records for
collec on, Case
approval & BDRS
UPW
AP/MA RD
Case Summary with 6-12
ques ons, Records for
collec on
Expert type
Case approval & BDRS
UPW
AP RD
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Chapter 2: Calling the member
Calling the member through the MD Triage model will follow the same scheduling
and calendar process as the MD Intake service line (see Module 2). You will receive
an invitation and an intake template from the Member Experience Coordinator
(MEC). Your call should follow the same script as an MD Intake call and is outlined
below.
1. Prepare
a. Review the intake that was sent to you by the MEC – what was the
primary question? If needed, review relevant background medical
information to help you focus your questions.
b. Call the member at the scheduled time
c. Introduce yourself
i. State your name and your role in the case. Let the member
know that you have been involved and are familiar with their
case and the BD report.
1. “Hi my name is David Harrison and I am a physician at
Best Doctors. I am calling to do an intake for your case.
Is now a good time to talk?”
2. “I would like to start by introducing myself. My role in
your case is that of a Best Doctors Associate Physician.
The purpose for this phone call is to discuss the issue or
issues that you would like us to address and I will provide
you with some information. At the conclusion of the call I
will send you a summary of our discussion and some
educational materials. We may also determine that
additional information and review is necessary and if so
we will discuss the next steps at the conclusion of the
call.”
3. In addition to my work with Best Doctors, I am a . . . ”
4. “Many times questions come up during this discussion.
Most of the time I can answer them but if not, we will
make a plan to make sure they are answered.
d. Set expectations – the member should understand what type of
information you are able to provide and make it clear that you are not
providing medical care, just information and education. Also clarify
that your comments to not replace the recommendations of their
treating doctors.
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e. Take a history as you would in clinical practice. Use the Intake
Template to document your discussion. Try to focus the member on
the 1 or 2 key issues for which the need help. Try to focus on the key
questions.
f. Summarize the discussion and determine next steps
i. “Thank you, this has been a very helpful discussion. I would like
to summarize briefly if ok with you. Please let me know if I misstate anything. My understanding is that Your history until now
is as follows”
ii. Then review their questions. Discuss general information, as you
are comfortable. Whenever possible refer to educational
materials that can be sent to the member at the conclusion of
the call (see Appendix A).
iii. Based on this discussion determine the optimal tier for the case.
If you believe expert review will be necessary, triage to the
most efficient Tier (see Figure 1) that will meet the member’s
needs as quickly as possible.
g. If necessary based on your selected tier, review records to be collected
i. Try to understand what tests (e.g. biopsies, imaging) have been
done and where
ii. Try to understand which doctors have been involved. Try to
understand which specialist if any has been driving the current
treatment plan
h. At the end, you can ask: “Are there any other questions that we did
not cover?”
i. Review next steps (as appropriate for your selected tier) and general
timelines for communication.
i. Sending a call summary and educational materials
ii. Record collection
iii. Expert review
iv. Report discusssion
j. Close the call
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Chapter 3: Deliverables for each Tier
Specific deliverables outlined below are covered in subsequent modules (e.g. Case Summary, BDRS).
Please make sure to review all modules in the curriculum. If you have any questions contact your lead.
For each tier make sure that the number of records and questions matches the guidelines provided in
Chapter 1.

Tier 1—Real-time Clinical Information
o Write a summary of your conversation, include, “questions to ask your doctor”
o Select pre-approved education to send to the member
o Email the team when the call is completed and be specific about any “next steps”
needed (e.g. FBD)

Tier 2—Expert Review Without Records
o Write a clinical vignette of your conversation (see Module on writing a clinical vignette)
o Email the team when the call is completed, identify the case as Tier 2, select the
specialty of the expert to review the case

Tier 3—Expert Review With Focused Records
o Write a clinical vignette of your conversation (see Module on writing a clinical vignette)
o Email the team when the call is completed, identify the case as Tier 3, select the
specialty of the expert to review the case, identify records for collection
o The MA involved with provide a report discussion at the end of the case

Tier 3R— Expert Review With Focused Records Including Primary Imaging
o Write a clinical vignette of your conversation (see Module on writing a clinical vignette)
o Email the team when the call is completed, identify the case as Tier 3R, select the type
of imaging expert to review the case, identify records for collection

Tier 4— Expert Review With Extended Focused Records
o Write a clinical vignette of your conversation (see Module on writing a clinical vignette)
o Email the team when the call is completed, identify the case as Tier 4, select the type of
expert to review the case, identify records for collection
o You may be asked to perform a Report Discussion at the conclusion of the case (See
Report Discussion Module)

Tier 5—Formerly known as InterConsultation (See Module 2 – MD Intake)
o Complete the intake template with extensive guidance for record collection
o Email the team when the call is completed, identify the case as Tier 5
o Identify the type of expert and work with PSD to select the specific expert
o Create a clinical summary
o At the end of the case complete the BDRS and UPW (see Report Approval module)
o Perform a Report Discussion (see Report Discussion Module)
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Appendix A: Vignette Guidelines
Writing the Vignette
Prior to submitting a case to the Lead, a vignette should be written based on a
telephone conversation with the member. We ask that the vignette is written in
flowing prose and that it is checked for grammar and spelling before
submission. Please try to write this vignette as if it were going to be written
about and read by a family member without clinical expertise; please use patientfriendly language and avoid medical abbreviations. Please also try to write
the vignette as if you were preparing to present the information
directly to an expert; non-standard abbreviations, sentence
fragments, mis-spellings and punctuation errors should be
avoided.
When writing vignettes, please note that the member information section should
always have the member’s height, weight, and body mass index (BMI) as well as a
complete medication list, including dosages. Please make sure to check the
spelling and names of medications. Often a patient doesn’t report a medication
name accurately, and might say that he is taking “Armor” for his thyroid when the
product is called “Armour Thyroid” (please note full and correct spelling of the
product). Attention to detail here is appropriate, as this is the only section that
the Lead cannot edit after the case is submitted.
The chronological description of illness should be a concise summary of the case,
2-3 paragraphs at most (EU vignettes should be limited to 1 page of a Word
document). The opening sentence should briefly summarize the case and should
tell the reader where the questions are going and what type of physician should
address them. For example, starting a vignette with “This is a healthy 56 y/o man
who eats well and works out three times a week” is not a helpful opening
sentence for a vignette about a member with an elevated PSA who has questions
about a prostate biopsy. A better leading sentence might be: “This is a 56 year
old gentleman with an elevated PSA who has questions about whether or not he
should have a prostate biopsy.” As another example, an opening sentence that
reads: “Early 2015 was scheduled for a routine colonoscopy” could be improved
grammatically and is not helpful for a case that is about atrial fibrillation. A better
leading sentence might be: “This is a 61 year old gentleman with asymptomatic
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atrial fibrillation and questions about management options.” Always include the
age, and we prefer that the words “gentleman” or “man” or “woman” are used to
indicate gender, rather than the generic “member.” Likewise, when referring to
the individual, please use the gender-specific pronouns “he” or “she” and please
refrain from using the repetitive and impersonal phrases “member says” or
“member reports.” For pediatric cases, please write from the perspective of the
family (e.g. “the child’s mother reports that...”) In general, race is not necessary
unless it is clinically relevant, e.g. a member of Ashkenazi Jewish descent asking
about the risk of cystic fibrosis or breast cancer. Lastly, as a tip that may help to
distinguish AtEs from other medical histories that are not usually patient-facing,
please be careful about (and avoid if possible) the phrase “the member denies.”
For those who are not accustomed to reading clinical histories, the term “denies”
often has an accusatory and confusing connotation.
When writing the vignette, try to focus on one topic in order to facilitate a
focused expert selection. For example, if a member calls with questions about a
thyroid medication and also about routine mammography, we would need to
engage multiple experts for the AtE (an endocrinologist cannot comment about
mammography), which is not ideal. We could send a case like that to an internist
to comment on both issues, but this would sacrifice the optimal expertise of the
responding expert. As a general strategy, if there are multiple issues, please help
the member select the issue of highest priority and process an ATE for that issue;
if needed, we can open a subsequent case for a second issue if absolutely
necessary.
The chronological description of illness should include symptoms and essentially
have all of the information for the case, except social, family, and past medical
history (unless relevant to a case, e.g. asking about breast cancer screening with
multiple close relatives who had breast cancer). If there is a further description of
symptoms needed that is not covered in this section, it can go in the symptoms
section, though that is usually not necessary. An exception might be fully
describing knee pain, e.g. location, exacerbating/alleviating factors, positions that
cause problems, radiation of pain, associated symptoms. If you described the
symptoms well in chronological description of illness, simply write “as above” in
the symptom section.
Try to use your clinical knowledge to ask the member additional questions about
their symptoms and to go past simply writing down what a member says.
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Examples include chest pain and sleeping problems. For chest pain, we want to
know when it occurs, what triggers it, exacerbating/alleviating factors, whether
shortness of breath is associated, whether palpitations are associated, family
history of arrhythmias/cholesterol issues/atherosclersosis/myocardial
infarctions/strokes, work-up to date, etc. For sleep, we need to know when they
go to bed, when they get up, typical amount of sleep at night, daytime sleepiness,
restless legs/associated symptoms, whether they nap (and if so, for how long),
medications tried in the past, workup to date, etc.
The past medical history section should be in prose as well and should start with
“The member has a past medical history of… He/she has a past surgical history
of…” This is where family history should go, as well as social history (it is better to
put in too much information if you are unsure of what to include, as we can
always remove extraneous information). For any of the medications that the
member lists, make sure you have a corresponding diagnosis listed under the past
medical history section. In some cases, the past medical history section will say
“none” though the medication list will include an antidepressant, a proton pump
inhibitor, and a statin. The lists should correlate.
Questions should be limited to 7 questions at most. If you feel that the member
is asking more, reach out to the Lead to help trim the list or to offer additional
compensation when there is a legitimate need for more than 7 questions. As a tip
when writing the question section, we recommend use of the following phrase
before the question list: “Please address answers to the member (write “family”
or “mother” or “father” if it is a pediatric case) in patient-friendly
language.” From there, number the questions and try to not write questions that
require prescriptive or definitive answers. For example, instead of asking “Does
the member need surgery?” consider writing “What are the indications for
surgery for this condition and what are the pros and cons of surgery?” Or, instead
of “Does the member have gout?” consider “Given the limited information in the
vignette, do you think that gout is a possible diagnosis for this member, and what
other diagnoses would you consider in this case?” For the last question for all
cases, please ask: “Please provide any additional comments and links to patientfriendly resources that you think this member might find useful (again, write
“family” if it is a pediatric case). Do not promise members that a specific
member-provided question will definitely be asked as provided - for medical
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appropriateness, the Lead may need to edit or exclude a member-provided
question from time to time.
Appendix A: Case that is not a good choice for a vignette based review
This case is sub-optimal for ATE for several reasons. First, there is a significant
amount of diagnostic testing performed that is “described” in the vignette. These
reports have impact potential and should be directly reviewed for this case. There is
also a potential high impact diagnosis here- a bowel obstruction could be due to
inflammatory bowel disease or cancer. Hence, a full IC is a good choice here.
“Member is a 50 year old male living in the UK reportedly diagnosed with
Diverticulitis in March 2015. Early 2015 (before his diagnosis) he had an episode of
abdominal pain. The pain was located in the mid-lower quadrant (suprapubic
region) and radiated to left hand side; it was a stabbing-like pain and was tender to
touch. A full bladder aggravated the pain, “it felt like the pressure of a full bladder
was pressing on his bowel”. The GP prescribed an antibiotic (name unknown) and
after 2 to 3 days the pain completely resolved. He was referred to a specialist and
underwent a flexi-sigmoidoscopy. This test confirmed the presence of diverticula
although the doctor was unable to pass the camera through the entire colon
because of a “blockage”. The specialist had said he will need to have a CT scan in
order to see the rest of the bowel but that there were no other issues or
abnormalities found. After the endoscopy procedure he suffered a similar episode
of abdominal pain; this time “more intense”. Again the GP prescribed an antibiotic
(name unknown) and after 2 to 3 days the pain completely resolved. He also took a
30 day course of the anti-spasmodic drugs Audmonal.
He has regular bowel movements that occur once or twice a day. He denies any
problems with passing urine and his urine is clear. He has a past medical history of
Asthma controlled by Flixotide and Serevent daily. His surgical history is:
circumcision (1995) and gallbladder removal (2003). He is a non-smoker. He
exercises doing cardiovascular training 1 ½ hours per week. He works as a
construction manager and has admitted to being under unusual amounts of stress
between January and March of this year. He stress levels are better now. He is
current height is 5’9 ½ and weighs 295 lbs. BMI: 42.9. He says he is allergic to “XRay dye”; when they removed his gallbladder he developed “nausea and sweats”
after the injection of contrast medium.
He follows a regular diet but since his diagnosis he has stop eating certain foods
(bread and fruit) and stop drinking alcohol. “I’m currently managing it with the aid
of anti-spasmodic drugs Audmonal (60 mg) three times a day and have no real
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symptoms. In the past 8 weeks I have had a reaction to eating fruit whereby I have
very bad diarrhea after eating fruit”.
He has contacted Best Doctors with general question regarding his condition.
Questions (please address answers to the member, in patient-friendly language)
1. Please provide an overview of Diverticulitis in layman’s terms, including how
it is treated.
2. How would you further evaluate this member and do you feel that any
testing is indicated at this time?
3. What are possible causes of a blockage during a flexi-sigmoidoscopy?
4. What is a CT scan, what does it entail?
5. What type a diet is recommended for a person with Diverticulitis? Are there
certain foods that should be avoided? Can I continue eating fruit?
6. Please provide any further comments that you feel would be helpful for this
member.
“
Appendix B: Case that is a good fit for a vignette based case
This case is a better choice for ATE (though it is not written the way we would like
an ATE to be written – the point of this Appendix B is the content choice for the
ATE). There is a single, focused issue at hand. While there was diagnostic testing, it
was interpreted as normal as would be expected in the clinical scenario. Symptoms
are well described and the proposed plan from the treatment team is clear.
Questions are focused and easily addressed by the expert based on available data.
“This is a 34 year old man living in Australia.
The patient has had acid reflux on and off for a period of 8 years. About 4 years
ago he had it constantly for about a year. He took a supplement called Liv 52 liver
support and the condition eased.
In the last month he has been regularly getting reflux again with acid refluxing into
his mouth, along with stomach cramps and a ‘churning’ sensation in his abdomen
as if he needs to open his bowels.
He has had blood tests, CT scan, and a breath test for helicobacter pylori which
have not shown any abnormalities. His GP has suggested it may due to something
he is eating and he is avoiding spicy foods and drinking warm water.
His GP has suggested that the next step would be to have endoscopy examinations
attended.
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The member has not had endoscopy attended in the past and is anxious about
undergoing this type of procedure.
MEDS: Nil medications
PMH/PSH renal stones
Wt 82 kg Ht 178 cm BMI 25.9
ALLERGIES-Nil Known
This member wishes to ask…
1/What is the risk of cross infection from a previous patient undergoing endoscopy
with the same instrument. How is the instrument sterilized?
2/Please explain what I am to expect for an upper endoscopy and a lower
endoscopy-what will happen to me? What are the risks/side effects associated with
endoscopy.
3/ What information can a doctor obtain from performing endoscopy? Is there an
alternative to endoscopy that will give you the same information?
Appendix C: Example of a case before and after editing
This version needing editing!
Member reports that just prior to June 13, 2015 Member woke having blurry vision to right eye that
cleared throughout the day. June 13, 2015 Member reports waking up to binocular double vision,
Member states that if she were to cover one eye the double vision would be eliminated. She also
complained of confusion and fogginess, insomnia, rapid heart rate, chest pain and diarrhea. Member
reports head tingling with facial pressure to right upper quadrant of her face. Member states she has a
long history of sinus issues; thinking this is sinus related she started on antibiotics (Augmentin) in which
she had at home and a decongestant (Sudafed). Member states condition was not resolving and she
called her PCP for an appointment for evaluation; PCP office directed to ER for evaluation and
treatement. ER performed a CT scan which Member states was unremarkable. Member sent home to
continue on Augmentin. Member evaluated by an Optometrist who stated that 2 of the nerves were not
working and that she required a referral to a neurologist or a neuro-opthamologist. Member then
evaluated by an ENT who repeated the CT scan which again presented unremarkable. ENT did a nasal
scope which Member reports was normal. ENT referred Member to an ENT surgeon who evaluated the
Member on July 10, 2015 who states that the sinuses are within normal limits but she did have a deviated
septum, and cobblestoning secondary to GERD. Member reports that the surgeon did not feel the
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surgery for the deviated septum would be beneficial and to have the MRI with and without contrast on
July 23, 2015 and consult with Neurologist and or neuro ophthalmologist. Member reports seeing neuroophthalmology on Sept 18, 2015 and on a wait list for Neurology. Member reports speaking to a
personal friend who is a RN who had similar symptoms and was Vitamin B12 deficient; Member states she
started taking Vitamin B12 7/17/15. On 7/18/15 Member reports symptoms greatly improved over the
course of the weekend; increased energy, fogginess resolved, insomnia improved, rapid heart rate and
chest pain resolved. Member also stopped Zantac on 7/16/15 and denies further diarrhea. Member
reports that the double vision has improved but remains at about 20%. Member states she had a
headache to the right side of her head last evening 7/19/15.
Edited version (Please note the complexity of this case. Depending on the questions that the
member has, a follow-up IC may be recommended for detailed records review and personalized
recommendations)
This is a 53 year old woman with a long history of sinus problems who awoke in early June with blurry
vision in the right eye that cleared throughout the day. On June 13, 2015, she had double vision. If she
were to cover one eye the double vision would be eliminated. She also complained of confusion and
“fogginess”, insomnia, rapid heart rate, chest pain and diarrhea. She reported head tingling with facial
pressure to the right upper quadrant of her face. Because of her sinus history, she started antibiotics
(Augmentin) that she had at home and a decongestant (Sudafed). Her symptoms did not resolve. She was
directed by her PCP to the ER, where a CT scan (presumably of the head) was unremarkable. She was sent
home to continue on Augmentin. She was evaluated by an Optometrist who stated that "2 of the nerves
were not working" and who suggested a referral to a neurologist or a neuro-ophthalmologist. She was
evaluated by an ENT who repeated the CT scan which again was unremarkable. Nasal endoscopy was
normal. An ENT surgeon evaluated her on July 10, 2015 and told her the sinuses were within normal
limits but that she did have a deviated septum, and cobblestoning secondary to GERD. The ENT surgeon
did not feel that surgery for the deviated septum would help her symptoms. The surgeon did suggest an
MRI with and without contrast (presumably of the brain) and a consult with a neurologist and/or neuroophthalmologist.
A friend told her she had similar symptoms and was found to be Vitamin B12 deficient, so the patient
started taking Vitamin B12 recently. A few days later, her symptoms greatly improved, with increased
energy, improvement in her mental fogginess and insomnia, and resolution of her rapid heart rate and
chest pain. She reports that the double vision has improved but remains at "about 20%."
Appendix D: Example of a case before and after editing
Version Needing Improvement
Member states since about April she has been going through with some stressful
situations.
Member states she was experiencing chest pain and SOB.
Member states all cardiac concerns were ruled out and it was thought to be acid
reflux related.
Member states stressful situations arose again in July and August, with symptoms.
In August member noticed that she was frequently clearing her throat
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TRIAGE AND TIERS
Member states she has been taking gas X, alka seltzer chews and pepcid ac "at
least one medicine daily, sometimes to relieve the symptoms and other times to
prevent the symptoms from coming on"
Member mentioned it to her endocrinologist who referred member to ENT.
ENT - "inflammed voice box d/t acid reflux"
Member states she was prescribed Pantoprazole 40mg BID for an 8 week course.
Member states she is concerned about the high dose of the medication and is
worried she will be stuck taking the medication long term to control her symtpoms.
Member has not started to take the medication
Symptoms:
Symptoms are better or worse depending on the stressful situations that she is
dealing with.
Chest pain would be present after eating meals and at night the chest pain would
also be present or more pronounced".
Currently member states she is careful about what she eats and doesn't eat late at
night to help relieve the symptoms.
Member took out coffee, tea, wine, spicy foods, and sour foods for her diet. "Cut
back on fruits and vegetables; eating more eggs, fish and rice"
Will take anti-acid chews and a gax-X at night to prevent acid buildup over night.
Need to Clear throat.
Worse first thing in the morning, and during the day after taking for long periods of
time"
Member states MD wants her to take the Pantoprazole to reduce the inflammation
on her voice box.
Past Medical History
Osteopenia
Hypothyroidism
Seasonal allergies
Questions
What is the recommended dose for Pantoprazole? When would it be necessary to
prescribe the medication Pantoprazole 40mg BID?
Do you think that Pantoprazole 40mg Once daily would be effective for member's
symtpoms and should be trialed before doing BID? if so, when would you
recommend increasing to 40mg BID?
After the 8 weeks of Pantoprazole will member's body become dependent on the
medication?
What can member expect after taking the drug for the 8 weeks time? If it proves to
be helpful will her boby then need the medicaiton to further prevent symptoms. If
it helps reduce the inflammtion on the voice box will the inflammation then come
back once the drug is stopped?
Is there a concern with taking the other 3 medications long term? Gas X, Pepcid ac
and alka seltzer on a daily basis as long as it is taken as recommended?
Are there any negative side effects associated with Pantoprazole and osteopenia?
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TRIAGE AND TIERS
What complications might arise from taking Pantoprazole 40mg BID for 8 weeks, if
any?
Edited version
This is a 57 year old woman with chest pain and shortness of breath who has been
diagnosed with gastroesophageal reflux and prescribed pantoprazole. Since April,
the member has been experiencing “stressful situations.” She has had chest pain
and says that cardiac concerns were ruled-out and that the pain was thought to be
related to acid reflux. She experienced additional stress in July/August, again
causing symptoms. In August she also noticed that she was frequently clearing her
throat. The member has been taking Gas-X, Alka Seltzer chews, and Pepcid AC "at
least one medicine daily, sometimes to relieve the symptoms and other times to
prevent the symptoms from coming on."
The member saw her endocrinologist (she has a history of hypothyroidism and
osteopenia) and mentioned her symptoms, at which point she was referred to ENT.
She says the otolaryngologist told her that she had an "inflamed voice box due to
acid reflux". She was prescribed an 8 week course of pantoprazole 40mg twice
daily. The member is concerned about the high dose of the medication and is
worried that she will have to take it long-term to control her symptoms. She has
not started to take it.
Symptoms
The member's symptoms vary depending on how much stress she is under. She
can have chest pain present after meals and at night as well. Currently she is
taking care with what she eats and does not eat late at night to help her
symptoms. She has eliminated coffee, tea, wine, spicy foods, and sour foods from
her diet and also cut back on fruits and vegetables and eats more eggs, fish, and
rice. She takes anti-acid chews and a Gax-X at night to prevent acid buildup
overnight.
The member also feels a need to clear her throat, worse first thing in the morning
and during the day after talking for long periods of time.
Past Medical History
The member has a past medical history of osteopenia, hypothyroidism, and
seasonal allergies.
Questions
Please address answers to the member in patient-friendly language.
1. What is the standard dose of pantoprazole for the treatment of gastroesophageal
reflux? When would it be necessary to prescribe 40mg twice daily? Could a lower
dose be tried before increasing to twice daily, and if so, how long would you wait to
see if the symptoms were relieved before increasing the dose?
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2. In general, do patients become “dependent” on pantoprazole after taking it for
eight weeks?
3. What can the member expect after taking the drug for the 8 weeks? If it proves
to be helpful, would you anticipate that she will continue to need the medication to
further prevent symptoms and/or to reduce inflammation in the voice box?
4 Is there a concern with taking Gas-X, Pepcid AC and Alka Seltzer long term on a
daily basis if taken as directed by the packaging?
5. Has pantoprazole been shown to cause bone loss or worsen osteopenia? What
other complications/side effects might occur from taking pantoprazole 40mg twice
daily for 8 weeks, if any?
6. Please provide any additional comments and links to patient-friendly resources
that may be helpful for this member.
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