25 May, 16 | by EBM
By Dr. Geoffrey Modest
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 (see doi: 10.1136/bmj.i2139).
- 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). This number was based on a record review of a population-based study of New York Hospitals reported in 1993.Overall there was a 4% incidence of adverse events reported in the hospitalized patients.
- A 2004 report from the Agency for Healthcare Quality and Research Patient Safety Indicators for the Medicare population estimated 195,000 deaths from medical errors per year (data from 2000-2002). This study found that of 37,000,000 admissions, there was an adverse event rate of 3.1%, a lethal adverse event rate of 0.7%, 389576 preventable deaths over these years, which they extrapolated to 2013 to be 251,454 preventable lethal adverse events.
- The US Dept of Health and Human Services/Office of Inspector General examined health records of hospital inpatients in 2008, finding 180,000 deaths/year from medical errors in those on Medicare. This study found that of 838 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 deaths, which they extrapolated to 2013to be 219,579 preventable lethal adverse events.
- A 2004 study of 3 tertiary care hospitals (2 community-based teaching hospitals, both urban with one in the Mid-west and one Northeast, and one academic hospital in the West) finding that of 795 admissions, there was an adverse event rate of 33.2% (!!!), a lethal adverse event rate of 1.1%, 100% felt to be preventable, leading to 9 deaths, which they extrapolated to 2013 to be 400,201 preventable lethal adverse events
- A 2002-7 study of 10 hospitals in North Carolina, finding that of 2341 admissions, there was an adverse event rate of 18.1%, a lethal adverse event rate of 0.6%, 63% felt to be preventable, leading to 14 deaths, which they extrapolated to 2013 to be 134,581 preventable lethal adverse events
- The summary findings were the same as those of the AHRQ/Medicare study, since its 37M admissions so dwarfs the other studies in the weighted average. (So, estimated number of preventable deaths was set at 251,454 for 2013)
- 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 may 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).
So, there are certainly several issues here:
- 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, either human or systems errors that could lead to death. And, accurate numbers still assume that the people or the institution involved is willing to acknowledge that a preventable cause of death occurred.
- 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’t looking hard enough?), but still, finding up to 1% of admissions were associated with preventable deaths is shocking….
- There are many methodological concerns with the data in this report:
- How accurate are the data collected (and how do they define a death as preventable )?
- 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 nonteaching hospitals, in small and large hospitals, in urban and rural hospitals, in hospitals with a slew of specialists and not, etc.
- How extrapolatable is the preventable death 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 done in the above study is based only on the number of admissions in 2013 vs the number in the year studied
- 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)
- One very related issue to me is the remarkably backward 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 necessary. 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 take care of their diabetes, hypertension, depression, domestic violence/other social issues, and their preventive care issues, etc.). And giving us the time and associated reimbursement to allow us to really take care of the patients’ problems, be accessible to avoid unnecessary ER visits and thereby decrease 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 never 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 patients 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……and, in many cases, they become delirious and are put on unnecessary medications which lead to significant morbidity.
- Of note, the April 30 issue of Lancet had a brief article and relevant editorial supporting a fundamental reworking of primary care for the NHS in the UK, with a large program to increase primary care recruitment, support primary care, streamline bureaucracy and improve reimbursement (see https://www.england.nhs.uk/ourwork/gpfv/ for a 5 year plan). There is also a report Primary Care by the House of Commons Health Committee “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” — 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)…