Friday, December 6, 2013

Hospital Admission Is the Third Largest Cause of Death!

While writing an essay on Medicare spending, this quote from an article entitled The Hospital Is No Place For the Elderly was encountered:

"Hospitals are fine for people who need acute treatments like heart surgery. But they are very often a terrible place for the frail elderly. ‘Hospitals are hugely dangerous and inappropriately used,’ says George Taler, a professor of geriatric medicine at Georgetown University and the director of long-term care at MedStar Washington Hospital Center. ‘They are a great place to be if you have no choice but to risk your life to get better’."

The statement seemed a bit harsh at the time—most people would not consider a hospital stay as being dangerous in itself—but it was re-quoted as is. The very next day an article was published in the New York Times by Tina Rosenberg: To Make Hospitals Less Deadly, a Dose of Data. She presented results from a recent study that indicated that adverse events encountered by patients in hospitals were far higher than previous estimates had suggested.

"Until very recently, health care experts believed that preventable hospital error caused some 98,000 deaths a year in the United States — a figure based on 1984 data. But a new report from the Journal of Patient Safety using updated data holds such error responsible for many more deaths — probably around some 440,000 per year. That’s one-sixth of all deaths nationally, making preventable hospital error the third leading cause of death in the United States. And 10 to 20 times that many people suffer nonlethal but serious harm as a result of hospital mistakes."

These numbers are astonishing! This government source (2010) lists annual deaths from heart disease at 597,689 and cancer at 574,743. The next category, chronic lower respiratory diseases, comes in at 138,080. Accidental death is fifth on the list at 120,859. One begins to wonder why we worry so much about deaths from drunk driving when the carnage is so much greater in our hospitals than on our highways.

Another way to view these numbers is to compare this to deaths from airplane crashes. The rate is equivalent to 1205 deaths per day. That is equivalent to about four commercial aircraft crashes per day. Can you imagine what would happen if four aircraft crashed in a single day? The entire industry would be shut down indefinitely.

The report Rosenberg referred to can be found here. She chose to pursue the issue of lax data keeping that makes accumulating such numbers so difficult and so uncertain. Here we will be more interested in extracting information from that report, and learning more about the credibility of the reported estimates.

The report provides this background information:

"Based on 1984 data developed from reviews of medical records of patients treated in New York hospitals, the Institute of Medicine estimated that up to 98,000 Americans die each year from medical errors. The basis of this estimate is nearly 3 decades old; herein, an updated estimate is developed from modern studies published from 2008 to 2011."

The report uses the term "preventable adverse event" (PAE) to describe any harmful effect on a patient due to caregiver error. The observable effects from such mistreatment are not necessarily immediately recognizable. Some may take years to appear. The report lists some illustrative examples that also serve to indicate how difficult it is to arrive at an accurate estimate of the totality of PAEs.

"The harmful outcomes may be realized immediately, delayed for days or months, or even delayed many years. An example of immediate harm is excess bleeding because of an overdose of an anticoagulant drug such as that which occurred to the twins born to Dennis Quaid and his wife. An example of harm that is not apparent for weeks or months is infection with Hepatitis C virus as a result of contaminated chemotherapy equipment. Harm that occurs years later is exemplified by a nearly lethal pneumococcal infection in a patient that had had a splenectomy many years ago, yet was never vaccinated against this infection risk as guidelines and prompts require."

The report was based on four preexisting studies of limited populations of patients. In each case a tool referred to as the Global Trigger Tool (GTT) was used to evaluate the medical records of the population of patients in order to discover suspicious events that might be PAEs. Physicians then reviewed these flagged records to decide if they should be considered as PAEs.

One study of Medicare patients is illustrative.

"Investigators looked at the medical records of 780 randomly selected patients chosen to represent the 1 million Medicare patients "discharged" from hospitals in the month of October 2008. The total number of hospital stays for the 780 patients during this period was 838 because some of the beneficiaries were hospitalized and discharged more than once during the 1-month index period. Using primarily the GTT developed by the Institute for Healthcare Improvement to find adverse events, investigators found 128 serious adverse events….that caused harm to patients, and an adverse event contributed to the deaths of 12 of those patients. Seven of these deaths were medication related, 2 were from blood stream infections, 2 were from aspiration, and the 12th one was linked to ventilator-associated pneumonia….The authors of this report estimated that "events" contributed to the deaths of 1.5 % (12/780) of the 1 million Medicare patients hospitalized in October 2008. That amounts to 15,000 per month or 180,000 per year."

Based on this single study, preventable deaths of Medicare patients alone far exceed earlier estimates for the entire population. And remember that the number of preventable events that caused harm was 10 times greater. That means that Medicare patients suffered from poor care at the rate of 1.8 million times per year. Truly, hospitals are dangerous places for old people.

The four studies used to arrive at a total population estimate were based on different types of patients from different regions. The Medicare data, for example, could not be applied to the entire nation. Based on the results of the four studies, as reported, the report arrived at this preliminary conclusion:

"Based on our extrapolation from the 4 modern studies, there are at least 210,000 lethal PAEs detectable by the GTT approach to record reviews."

However, there is plenty of evidence that medical records are not to be trusted. Doctors and hospitals not only get to bury their mistakes, they get to bury the evidence as well. These examples of sources of underreporting are provided.

"In a study that broke past the wall of silence about discovery of medical errors that were missing from medical records, Weissman and colleagues found that 6 to 12 months after their discharge, patients could recall 3 times as many serious, preventable adverse events as were reflected in their medical records. This study involved review of 998 medical records of patients hospitalized in Massachusetts for medical or surgical treatment from April to October 2003."

"….some medical errors are not known by clinicians and only come to light during autopsies, which have found misdiagnoses in 20% to 40% of cases. ‘Aggressive’ searches for adverse drug events and prompted self-reports from clinicians have shown a much higher rate of adverse drug events than are evident in the medical records. A comparison of direct observation for medication errors with review of documentation in medical records in 36 hospitals and skilled-nursing facilities found that far more errors were found by direct observation than by inspection of medical records."

"A recent national survey showed that physicians often refuse to report a serious adverse event to anyone in authority. In the case of cardiologists, the highest nonreporting group of the specialties studied, nearly two-thirds of the respondents admitted that they had recently refused to report at least one serious medical error, of which they had first-hand knowledge, to anyone in authority. It is reasonable to suspect that clear evidence of such unreported medical errors often did not find their way into the medical records of the patients who were harmed."

The method of surveying medical records also neglects to count errors of omission.

"Premature deaths as a result of medical errors may occur many years after the hospital stay because the patient’s care was not optimal or did not follow guidelines. Furthermore, lethal PAEs can been [sic] missed by the GTT and by physician reviews. The GTT does not detect diagnostic errors or errors of omission, especially those involving failure to follow guidelines. Lethal diagnostic errors have been estimated to affect 40,000 to 80,000 people per year including outpatients."

It has been estimated that it takes about 10 years before an accepted medical finding makes its way into general usage by physicians. This delay can be lethal.

"Physicians have been indefensibly slow to adopt guidelines that would potentially prevent premature deaths or harm. One egregious example is the estimated 100,000 heart failure patients that died prematurely each year in the late 1990s because they did not receive beta-blockers. The efficacy of beta-blockers was established by a study published in the JAMA in 1982."

For all of these reasons, the estimate of PAEs based on the four studies had to be considered a lower limit. The final estimate essentially doubled the number of deaths and harmful events.

"Using a weighted average of the 4 studies, a lower limit of 210,000 deaths per year was associated with preventable harm in hospitals. Given limitations in the search capability of the Global Trigger Tool and the incompleteness of medical records on which the Tool depends, the true number of premature deaths associated with preventable harm to patients was estimated at more than 400,000 per year. Serious harm seems to be 10- to 20-fold more common than lethal harm."

This might also be conservative and could be considered a lower limit.

How could things be so bad? Who is responsible?

The aircraft crash analogy that was used earlier was first made by Captain Sulllenberger, the pilot who became famous a few years ago when he successfully executed an emergency landing in the Hudson River. The American Hospital Association once invited Captain Sullenberger to give them a talk on how lessons learned in enhancing aircraft safety could be used to improve the quality of hospital care. He gave them an earful. First he provided this background on aviation practices.

"Thirty plus years ago, before CRM (cockpit resource management), captains could be alternately Gods or cowboys, ruling their cockpits by preference or whim with insufficient consideration of best practices or procedural standardization…And first officers trying to do the right thing would never quite know what to expect. Some captains did not bother with check lists (and it was unclear who was responsible for what)."

"We worked to build a culture of safety that allows us to face an unanticipated dire emergency, suddenly, one for which we had never specifically trained, and saved every life on board…"

Then he pointed out that most medical errors are the result of system failures. Just as in the aviation industry, safety required the development of a culture where all participants were viewed as members of a team. A comparison is implied between the cowboy pilots of yesteryear and the doctors of today who choose not to bother with checklists, then he goes on to decry the current medical situation where it is assumed that when something goes wrong it is the result of an individual’s error.

"Conventional wisdom often has it that if a nurse makes a mistake, he or she should be terminated, but the vast majority of harmful events are due to system failures not practitioner error. The (health care) leaders are responsible for the maintenance of these support systems, not the caregivers. And the current punitive culture only drives problems underground where they can never be examined or solved."

In Sullenberger’s opinion, it is the hospital administrators who are at fault for not imposing systematic safeguards that could prevent most mistakes from occurring.

He continued on—optimistically.

"Federal legislation is about to link health care payments to the quality of service. I believe in ten years, when this is integrated throughout the system, we’ll look back at where we are today and will know that we were flying blind."

Meanwhile, stay healthy! Your life may depend on it.

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