{"id":1057,"date":"2016-05-25T15:08:19","date_gmt":"2016-05-25T15:08:19","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1057"},"modified":"2017-08-21T10:56:06","modified_gmt":"2017-08-21T10:56:06","slug":"primary-care-corner-with-geoffrey-modest-md-medical-errors-and-a-plea-for-primary-care","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/05\/25\/primary-care-corner-with-geoffrey-modest-md-medical-errors-and-a-plea-for-primary-care\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Medical Errors, and a Plea For Primary Care"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>There was a recent brief article looking at the approximate rate of medical errors leading to death, and suggesting that this was the 3rd leading cause of death in the US\u00a0(see doi: 10.1136\/bmj.i2139).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>A 1999 Institute of Medicine report, based on the 1984 Harvard Medical Practice Study and the 1992 Utah and Colorado Study, suggested that of the 180,000 reported iatrogenic deaths, 51% were preventable, though the lead Harvard researcher suggested that the number was closer to 78% (i.e. 140,400 preventable deaths).\u00a0This number was based on a record review of a\u00a0population-based study of New York Hospitals reported in 1993.Overall there was a 4% incidence of adverse events reported in the hospitalized patients.<\/li>\n<li>A 2004 report from the Agency for Healthcare Quality and Research Patient Safety Indicators for the Medicare population estimated\u00a0195,000 deaths from medical errors per year (data from 2000-2002).\u00a0This study found that of\u00a037,000,000 admissions, there was an adverse event rate of 3.1%, a lethal adverse event rate of 0.7%, 389576 preventable\u00a0deaths over these years, which they extrapolated to 2013 to be 251,454 preventable lethal adverse events.<\/li>\n<li>The US Dept of Health and Human Services\/Office of Inspector General\u00a0examined health records of hospital inpatients in 2008, finding 180,000 deaths\/year from medical errors in those on Medicare. This study found that of\u00a0838 admissions, there was an adverse event rate of 13.5%, a lethal adverse event rate of 1.4%, a 44% rate of preventable deaths, leading to 12\u00a0deaths, which they extrapolated to 2013to be 219,579 preventable lethal adverse events.<\/li>\n<li>A 2004 study of 3 tertiary care hospitals (2 community-based teaching hospitals, both urban with\u00a0one in the Mid-west and one Northeast,\u00a0and one academic hospital in\u00a0the West)\u00a0finding\u00a0that of 795\u00a0admissions, there was an adverse event rate of 33.2% (!!!), a lethal adverse event rate of 1.1%, 100% felt to be\u00a0preventable, leading to 9\u00a0deaths, which they extrapolated to 2013\u00a0to be 400,201\u00a0preventable lethal adverse events<\/li>\n<li>A 2002-7 study of 10 hospitals in North Carolina,\u00a0finding\u00a0that of 2341\u00a0admissions, there was an adverse event rate of\u00a018.1%, a lethal adverse event rate of 0.6%,\u00a063%\u00a0felt to be\u00a0preventable, leading to 14\u00a0deaths, which they extrapolated to 2013\u00a0to be 134,581\u00a0preventable lethal adverse events<\/li>\n<li>The summary findings were the same as those\u00a0of the AHRQ\/Medicare study, since its 37M admissions so dwarfs the other studies in the weighted average. (So, estimated\u00a0number\u00a0of preventable deaths was set at 251,454 for 2013)<\/li>\n<li>And, none of these studies included deaths at home, or in nursing homes, or in an ambulatory setting (which is an issue, both in terms of hospitalized patients who may have been discharged from the hospital but\u00a0may have died relatively shortly thereafter from a hospital-related error, and because some patients undoubtedly die because of errors in medical care in the non-hospital setting itself).<\/li>\n<\/ul>\n<p>So, there are certainly several issues here:<\/p>\n<ul>\n<li>The quality of the data: the list of causes of death, per the CDC, is based on ICD coding, and there are no codes for diagnostic errors, poor judgment, inadequate skills, or, in general,\u00a0either human or systems errors that could lead to death. And, accurate numbers still\u00a0assume\u00a0that the people or the institution involved\u00a0is willing to acknowledge that a preventable cause of death occurred.<\/li>\n<li>It is pretty striking that the number of adverse events was so variable (why was the Medicare one in the 3% range, yet up to 33% in the 3 tertiary care hospitals? Is it how adverse events are classified? Is it that Medicare just wasn&#8217;t looking hard enough?), but still, finding up to 1% of admissions were associated with preventable deaths is shocking&#8230;.<\/li>\n<li>There are many methodological concerns with the data in this report:\n<ul>\n<li>How accurate are the data collected (and how do they define a death as\u00a0preventable\u00a0)?<\/li>\n<li>How extrapolatable are the data from a survey of 3 or 10 hospitals, or even the Medicare data, to the general population, in teaching and\u00a0nonteaching hospitals, in small and\u00a0large hospitals, in\u00a0urban and\u00a0rural hospitals, in hospitals with a slew of specialists and not, etc.<\/li>\n<li>How\u00a0extrapolatable is the preventable\u00a0death rate from 2002 or 2008 to 2013? Lots has changed. Part is that the degree of illness of admitted patients may have changed. Or the intensity of testing. Or doing higher risk procedures. and the extrapolation of preventable deaths to 2013 as\u00a0done in the above study\u00a0is based only on the number of admissions in 2013 vs the number in the year studied<\/li>\n<\/ul>\n<\/li>\n<li>But, the bottom line is that there are a huge number of potentially preventable deaths, that the number is probably in the general ballpark of what they report, and that as such a huge issue, we should be devoting large amounts of resources to deal with this (i.e., one might think that prioritizing this issue makes sense, perhaps over developing\/using another orphan drug for a rare disease, or devoting large amounts of resources to providing very expensive care to a terminal cancer patient where the benefit is on the order of a few months of additional life or less)<\/li>\n<li>One very related issue to me is the remarkably\u00a0backward nature of our health care system. It seems to me that the primary way to avoid preventable hospital-related deaths is to prevent hospitalization. Which for many of my patients in the 80-100 year old range, means preventing their going to the ER unless really\u00a0necessary. Which means redesigning the orientation and reimbursement of the health care system to value primary care, move away from the 10-20 minute appointments (which, in the era of electronic medical records, translates to 5-10 minutes actually spent with the patient during which time we\u00a0take care of their diabetes, hypertension, depression, domestic violence\/other social issues, and their preventive care issues,\u00a0etc.). And giving us\u00a0the time and associated reimbursement to allow us to really take care of the patients&#8217; problems, be accessible to avoid unnecessary ER visits\u00a0and thereby\u00a0decrease unnecessary hospitalizations. My experience is that when one of my frail patients goes to the ER for a likely minor problem, they are usually admitted (and I do not blame the ER physicians, since they see a frail person, do not know them, are not sure they will get outpatient follow-up, and feel that it is better to be safe than sorry. Though I almost\u00a0never get a phone call to see if we can see the person the next morning. And the reality is that about 50% of my elderly\u00a0patients admitted do not need admission, they often stay longer than they should, they decondition after 2 days, then they go to a rehab facility to recondition&#8230;&#8230;and, in many cases, they become delirious and are put on unnecessary medications which lead to significant morbidity.<\/li>\n<li>Of note,\u00a0the April 30 issue of Lancet had a brief article and relevant editorial supporting a fundamental\u00a0reworking of primary care\u00a0for the NHS in the UK, with a large program to increase primary care recruitment, support primary care, streamline bureaucracy and improve reimbursement (see\u00a0<a href=\"https:\/\/www.england.nhs.uk\/ourwork\/gpfv\/\">https:\/\/www.england.nhs.uk\/ourwork\/gpfv\/<\/a> for a 5 year plan). There is also a report <em>Primary Care\u00a0<\/em>by the House of Commons Health Committee &#8220;which emphasizes the need for increased funding of general practice to improve access to care and services for patients, such as extending the traditional 10 minute appointment time&#8221; &#8212; though I was unable to locate that report. And this is in the UK, which already has a universal, reasonably coherent\/connected, accessible system of care (i.e., already much beyond us)&#8230;<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Medical Errors, and a Plea For Primary Care  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/05\/25\/primary-care-corner-with-geoffrey-modest-md-medical-errors-and-a-plea-for-primary-care\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1057","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1057","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1057"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1057\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1057"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1057"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1057"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}