Evaluation of Behavioral Contracts and Resource Utilization in Intravenous Drug Use Patients Treated for Infective Endocarditis

Pierce Randall – Albany Medical College

Abstract: The U.S. is facing an opioid epidemic, leading to an increase in infective endocarditis (IE) cases among intravenous drug users (IDUs). Severe cases often require valve replacement surgery, but bias and stigma against IDUs can influence the decision to perform surgery, as these patients are at higher risk of re-infection. 16% of thoracic surgeons argue that surgery is futile without proper addiction treatment, and 48% of surgeons refuse to operate more than once, citing concerns regarding fairness and justice. The assumed increased resource utilization among the IDU population, such as re-do valve transplants and longer intensive care hours, potentially prevents multiple non-IDU patients from receiving care.

Consequently, many surgeons have turned to behavioral contracts - should the patient develop IE secondary to recurrent IDU, a second operation will not be offered. Behavioral contracts are used in medical practice to encourage patient adherence to treatment and promote accountability. However, their implementation overlooks the complex pathophysiology of addiction and raises ethical concerns regarding justice and non-maleficence.

A single institution retrospective review of IE in IDU and non-IDU populations was developed to compare resource utilization to improve clinical decision-making in treating IDU-IE patients and discuss ethical considerations of using behavioral contracts. This study found no significant differences between the IDU and non-IDU populations when analyzing utilization of resources deemed noteworthy by the Society of Thoracic Surgeons (STS), challenging existing biases. While behavioral contracts can be beneficial, they must be applied with accurate information to ensure they do not exacerbate existing healthcare disparities.

Keywords: Behavior Contracts, Resource Utilization, Intravenous Drug Use