Wednesday, November 3, 2010

Evidence of harm

We alluded recently to some of the perils of our healthcare system -- the errors, the unnecessary deaths, healthcare-associated infections, and even the idea that we have not done a good job accounting all of the harm that goes with our interventions. It occurred to me that, since you are not immersed in this stuff all day every day the way that I am, it might be helpful actually to put the issue in perspective through transparent data. Mind you, these data are not easy to gather or clean or interpret. So, the point estimates that are widely cited may be somewhat off. But think about it: even the problem is only one-half the magnitude reported, it is still mammoth!  

When we search the Centers for Disease Control and Prevention web site for latest statistics on mortality, we get to this page, where the familiar numbers confront us. These numbers do not change drastically year after year, and indicate that in 2007 the top four cause of death in the US remained cardiovascular disease (616,067), cancer (562,875), stroke (135,952), and lung disease (127,924). 

Here is something shocking, though: in the CDC's hierarchical accounting of the causes of death in the US, one of top three causes is incorrect. And this baffles me because for a decade we have known the third leading cause of death in the US to be something other than stroke. The cause is what I call fulminant iatrogenesis. What is fulminant iatrogenesis? Well, in Greek, the word for "doctor" is "iatre". In our medicalese we have adopted this root to describe complications arising from healthcare as "iatrogenic". We all know that there are adverse events, mistaken identities and such, and we even have an idea that there are somewhere in the range of 50,000-100,000 deaths attributed to hospital care itself, thanks to a well publicized report from the Institute of Medicine from 1999 with a memorable title of "To Err is Human". And since then we have heard echoes of other rather large numbers of deaths due to hospital-acquired infections, also somewhere in the vicinity of 100,000. But details and holistic picture of these numbers, whether there are there overlaps or are they really as outrageously high as they seem, have not been clarified well by the popular press. But is has been addressed in the medical literature, a decade ago. And while we continue to hear a constant din of hoofbeats of the safety police, it is still questionable what effect they have had.           

According to a paper that can be considered vintage at this point, appearing in JAMA in 2000 by Barbara Starfield, MD, MPH, from Johns Hopkins University in Baltimore, our US healthcare system is not so healthy. An accounting of deaths that can be attributed to various forms of contact with the healthcare system is shocking:  

Iatrogenic deaths/year in US hospitals

12,000: unnecessary surgery
7,000: medication errors in hospitals
20,000: other errors in hospital
80,000: nosocomial infections in hospitals
106,000: non-error medication adverse events

These numbers add up to 225,000 deaths/year from iatrogenic causes, and this broadly represents the third leading cause of death in the US after cardiovascular disease and cancer, and accounting for twice as many deaths as the CDC-listed 3rd cause, cerebrovascular disease. And please note that these numbers are actually far lower than those presented in the 1999 IOM for hospital deaths related to errors (48,000 -- 99,000), and at least a bit lower than the most recent CDC estimates for deaths from hospital-acquired infections (99,000). I call this "fulminant iatrogenesis". According to Starfield, what the above sum total of 225,000 fails to take into account is the additional 199,000 deaths related to adverse effects of outpatient treatment. So, putting these together, there are 424,000 iatrogenic deaths in the US annually. Now, this is something to shout about! We know that in the US we do not do a very good job following evidence, even when there is such available, and even when it is relatively solid. So, with all of the caveats and care that I regularly discuss on this site, we really need to do a better job streamlining processes and implementing best available evidence as appropriate. This frightening number of nearly 1/2 million deaths due to contact with the healthcare system needs to become branded onto our national psyche. What a travesty that in a nation that outspends every other in healthcare, that has possibly the worst access to care of all developed nations, we should have such a staggering number of potentially preventable deaths from iatrogenic causes.  How many lives does this kind of system have to be responsible for saving in order to balance this risk-benefit equation?   
Another premier cause of death hidden in the CDC numbers is smoking. In fact, back in the late 1990s the estimate was that the annual death toll in the US from smoking-related causes is 440,000. Of course this is not on top of the causes of death listed, but overlaps with many of the proximal causes listed. Add to this our growing obesity epidemic, and the new data that by 2050 we can expect 1 in 3 Americans to have diabetes mellitus, and you have yourself a tidy public health catastrophe. 

Now, some people may consider this to be a "tu quoque" logical fallacy. Or that this is a straw man. They may say that we are already applying evidence-based methods to address this monster. And they will, of course, be correct, to an extent. The methods that we are applying are not always evidence-based and the incentives system growing up around these measures is far from the latest and greatest in what social sciences tell about human nature and successful behavior change. Most importantly, 10 years later the evidence indicates that we have not moved this hospital death meter, not one little bit. 

So, my response to criticism of my logic is: yeah, whatever. A straw man this massive could eat Tokyo. To me these are startling numbers. We need everyone committed to science and evidence to participate in finding solutions, and constantly reflect on the medical errors that are so pervasive and so deadly. If you pay attention to the evidence of harm, there is no escaping the conclusion that our house is indeed made of glass.   

1 comment:

  1. Hi Marya, I have just discovered your blog and am enjoying your posts. More recent reports support your comments about the rate of iatrogenic injury/death.