Hserv 482#7 Medical Care and Health

WARNINGAttending this presentation

may be dangerous to your perceptions of health care

Learning ObjectivesAnalyze a study suggesting that medical care

improves life expectancy

Present the data on medical harm in the US and other countries

Experiences with health carePersonal experiences

– Family– friends

How could one study the effect of medical care on health?

Cost of medical care~50% of total world health care bill is spent in the US

(2005)

2005: $1.94 trillion and 16.2% of GNP

Health care costs absorbed a 24.1 percent share of the nation's economic growth between 2000 and 2005

http://ucatlas.ucsc.edu/

Sagar BU 2005

Health Care Insurance Profits $100 billion (2005)

Sagar BU 2005

Effect of antibiotics?

Wilson 2005 IJE

Vaccinations?

JAPAN?

Spend more money on health care?

Scientific Study

Medical care has the capacity to improve mortality and quality of

life

Bunker Paper looked at benefit of medical care & preventive services

on average life expectancy has increased from ~45 to ~75 years in rich countries

SUMMARYHealth care improving quality of life

ALL TOLD– 5 of 30 years life expectancy gain last century in the

USA could be attributable to preventive and curative health services

FLAW?

Could medical care cause harm?Personal experiences

– Family– Friends

How would you study medical harm

Medical harmMistakes

Adverse or bad outcomes, – No mistakes made

medical harm a leading cause of death, wherever it has been

looked at DAMAGED CARE

• Studies in USA (3 states), UK, Australia, New Zealand, Denmark, Canada and France

Medical Harm

• Harvard Study NEJM 1991• Australia (1995)• IOM TO ERR IS HUMAN

report (2000)• Utah, Colorado study

published in 2000• UK 2001, 2004• Denmark 2001• New Zealand 2002• Canada 2004• France (2004)

ADVERSE EVENTS: 3.7% of admissions

1/4 were result of negligence

Harvard Malpractice Study

DEATHS

13.6% of adverse events

Brennan et. al. NEJM 1991

over half (51.3%) the result of NEGLIGENCE

- 19% of adverse effects drug related- 14% wound infections- 13% complications from technical procedures

ADVERSE EVENTS (3.7%):

Brennan et. al. NEJM 1991

ConclusionsGetting admitted to a hospital has a risk of death from medical care

approaching 1%Varying percentage of deaths preventable, while

half or more are NOT preventableVarying terminology:

– US: errors, mistakes, negligence, iatrogenic injury, substandard care– Canada, NZ, Australia, UK, Denmark: preventability– Australia: human error

Highest Life ExpectancyAnd disability free years

Lowest Life ExpectancyAnd disability free years

Life expectancy disparityis 16 years

ACLS Professional Provider ManualEpinephrine "Although epinephrine has been used for years in resuscitation, there is little data to show that it improves outcomes in humans" pg 49

Phillips 1998

Los Angeles County Medical Malpractice Slowdown, January 1976

55 to 153 deaths did not occur because of the elective operations not performed because of the strike

88 fatalities occurred among 2171 patients transferred out of the county during the strike, of which 25 could be ascribed to the strike, the remainder to ongoing “patient dumping”

OTHER DOCTOR STRIKESBogota Colombia in 1976 a 52-day period. The death

rate went down 35% during that time.

In Israel in 1973, during a month-long strike, the death rate dropped 50%. The last time the death rate had been that low was when there was a doctor's strike 20 years before."

Croatia doctor's strike in 2003 currently being studied, clearly no decline in health

Johns Hopkins Prof. Barbara Starfield Although the medical literature does not dwell on the damage

caused by inappropriate care, several studies have shown that the third leading cause of death in the United States, after heart disease and cancer, is medical intervention, including both tests and therapies. Over the past few years, the annual number of reports of adverse effects from prescribed medications (including deaths) has been increasing. A conservative estimate of the percentage of deaths in the United States that result from adverse effects of medical treatment is ten percent. In other words, an estimated 275,000 of the total of 2.5 million deaths that are annually attributed to specific diseases are really a result of harm from interventions.

Nov/Dec 2005

and

Medical harm Olympics Prevalence(% pts ≥ 1 AE)

% AEsPrevent

Adm.% deaths

Canada (2000) 7.5 37 1.6

US: Utah, Colorado (1992) 2.9 NR 0.2

Australia (1992) 16.6 51 0.8

US: New York State (1984) 3.7 NR 0.5

UK: London (1999-2000) 10.8 48 0.9

UK (2004) 10.9 ~50 1

New Zealand (1998) 12.9 37 0.6

France (2004) prospective 0.6/1000 days

35 ~.1 per adv ev

Denmark 9 40 ?

Doctorspublic

discount medical harm

ideas

The survey was conducted by telephone from July 7 to September 5, 2004 among a randomly selected nationally representative sample of 2,012 adults 18 years or older. Interviews were conducted in English and Spanish by Princeton Survey Research Associates. The margin of sampling error is +/-2 percentage points overall. The margin of sampling error will be higher for results based on subsets of respondents. Sampling error is only one of many potential sources of error in this or any public opinion poll. Before answering questions on medical errors, respondents were all read a common definition of medical errors. They were told, "Sometimes when people are ill and receive medical care, mistakes are made that result in serious harm, such as death, disability, or additional or prolonged treatment. These are called medical errors. Some of these errors are preventable, while other may not be." Trend data is from the Kaiser Family Foundation/Agency for Healthcare Research and Quality Americans as Health Care Consumers: The Role of Quality Information (1996), The Kaiser Family Foundation/Agency for Healthcare Research and Quality National Survey on Americans as Health Care Consumers: An Update on the Role of Quality Information (2000), and the Harvard School of Public Health/Kaiser Family Foundation Medical Errors: Practicing Physician and Public Views (2002)

Kaiser Poll 2004

Kaiser Poll 2004

Kaiser Poll 2004

Kaiser Poll 2004

Public Health Textbook:“with modern investigations and treatments, patients are now

regularly saved and make very good recoveries from infections, injuries, and a variety of other conditions that were almost uniformly fatal even a few years ago. Surprisingly it is more difficult to demonstrate conclusively the impact of these medical advances on the health of whole communities” pg 238– Detels, R., W. W. Holland, et al., Eds. (2002). Oxford

Textbook of Public Health. Oxford, Oxford University Press.

Are there aspects of health care that are beneficial?

Role of Primary Care

Primary Care Role

Social supports for lacking for poorer segment – primary care can address

Poorer population is sicker – primary care can take of most problems

Effective Primary CareEasy access (hours of operation, location)

Non-specialists:

– Mid-level practitioners with time to talk

Consistency:

– same staff person on successive visits and in follow-up to spend more time

Not prescribing medicines just to get people out of the clinic

Universal CoveragePolitical issue: UN Universal Declaration of Human

Rights, of which US is a signatory

It has not been a campaign issue– in spite of 70% of population wanting it

Student opinion on whether Universal Coverage will improve US health?

Web of Influence

“To conclude, a universal health care system is definitely the right policy tool for delivering care to those in need, and for this it must be respected and supported. However, investments in health care should never be confused with, or sold as, policies whose primary intent is to improve population health or to reduce inequalities in health. Claims to that effect are misleading at best, dangerous and highly wasteful at worst.”

Chapter 5, Universal Medical Care and Health Inequalities: right objectives, insufficient tools. Roos, Brownell, Menec (2006). Oxford University Press.

Woolhandler et. al. 2002

Summary

Medical care has not been shown to positively affect the health of whole populations

Health care in idealized circumstances can have beneficial effects

Medical harm causes many deaths

Primary care may be the best part of health care

I still work as a doctor because I believe it can help people, and I'm not saying you shouldn't see a doctor if you are sick