Transcript Health Care

Medical errors :
Opportunities to evaluate and improve
healthcare
Signs of disease
in for-profit healthcare
Joe Schirmer, Member
United Professionals
for Quality Health Care 1199W, SEIU, AFL-CIO
Toronto, Canada, June 2012
Health Care Quality
Factors underlying medical errors also
affect health care quality
For profits provide lower quality healthcare
Devereaux, CMAJ 2002 Woolhandler, NEJM 1997
50 to 55% receive recommended care.
Lower compliance for conditions requiring more
interaction e.g., counseling, education, histories
McGlynn, NEJM 2003. Schuster, McGynn: Millbank Quarterly 1998.
Access matters:
US veterans receive 67% of recommended care
Asch: NEJM 2006
Data for medical errors
Retrospective, Prospective studies, Patient surveys
Retrospective studies of hospital records
US found 2.9 to 3.7% errors.
Brennan, NEJM 1991. Thomas, Medical Care 2000.
Canada found 7.5% errors (2.8% preventable)
Baker , CMAJ 2004.
New Zealand and Australia found 12.9% and 16.6% errors
Wilson, Med J Aust 1995. Davis, NZ Ministry Health 2001.
Prospective and intensive studies find more errors
46% of 1047 patients had adverse events
Andrews: Lancet 1997
ICU patients had 1.7 errors/day
Donchin: Crit Care Med 1995
13% surgery patients had complications due to errors
Wanzel Can J Surg 2000
Daily review of pediatric surgeries found 1/3 cases
with adverse outcomes due to errors
Proctor J Pediatr Surg 2003
Listen to Patients!
Surveys report 15-37% error rates.
Nat Patient Safety Found. 1997. Kistler, Arch Intern Med 2010.
Ghandi, J Gen Int Med 2000. Northcott, I J Quality in Health Care 2007.
Fowler,Jt Comm J Qual Patient Safety 2008. Weissman, Ann IntMed 2008
A 2012 NPR survey of recently hospitalized patients
11% reported getting wrong diagnosis, treatment or test.
8% reported they got an infection while in hospital.
30% saw poor communication among health care providers
24% reported doctors or nurses did not communicate info about
treatment or condition with patient or family.
72% want doctors to spend time discussing broader health issues
affecting health in addition to their current issue at hand.
53% see a major problem with doctors or nurses not spending
enough time with patients.
NPR, RW Johnson, Harvard School of Public Health Poll 2012
Listen to recently hospitalized patients views
of leading reasons for rising health care costs
85% Drug companies charge too much
78% Hospitals charge too much
75% Insurance companies charge too much
70% People not taking good care of their
health, so need more medical care
61% fraud and abuse by some hospitals,
doctors and nursing homes
58% doctors charge too much
NPR, RW Johnson, Harvard School of Public Health Poll 2012
Who profits from health care?



Investors are typically absent from the
practice of health care
They interact neither with stressed health
care providers nor with the stressed and
suffering human beings called patients
Investors own pharmaceutical companies
nursing homes, hospices, home health
care agencies,, dialysis clinics, hospitals,
HMOs, and clinics.
Most Nursing Homes are operated as For-Profits
in US (67%), Canada (52%) and UK (>50%)
For-Profit Nursing Homes
provide lower quality care:

11% lower staffing
9% more incidence pressure ulcers
7% more use of restraints
10% more regulatory deficiencies

Meta-review of 82 studies by Commodore et al, BMJ 2009



More Profit, More Problems
Data from 1100 California nursing
homes shows that those with profits
in the top 14% were associated with
significantly more and more serious
deficiencies.
Nursing homes with more nursing
hours per patient (staffing) had
better quality care. O’Neill, Med Care 2003
Nursing Home Drug Usage




1.6 million residents in US
61% take >9 medications/day
1.9 million adverse drug events/year
For each $1 spent on drugs, another
$1.33 is spent on drug related
morbidity and mortality, costing 7.6
Billion/year
Crespin, Am J Geriatric Pharmacotherapy 2010
Antidepressants in Nursing homes



Antidepressant use rose from
20% in 1996 to 48% in 2006.
35% of ADEs in nursing homes are
caused by psychotropic meds.
63% of these are preventable.
Overuse of psychotropic meds
doubles the risk of falls.
Gurwitz, AM J Epi 2000. Hanlon, J Am Med Dir Assoc 2010.
For-Profit Hemodialysis

75% of US hemodialysis care is for-Profit

208,000 US patients receive hemodialysis

20 to 25 % of these patients die each year

For profit patients are 8% more likely to
die. If care were provided in not-for-profit
settings, approximately US 2,500 deaths
could be avoided each year.
Review of 8 studies including 500,000 patient years.
Devereaux et al, JAMA 2002
For-profits cost more, deliver less




For profit hospitals charge 19% more
because of higher administrative costs,
bonuses and paying investors from profits.
Two largest for-profit hospital chains paid
$2 Billion to US for fraud.
For-profits have shorter length of stays
and higher patient mortality and less
staffing when controlling for other factors.
Silverman NEJM 1999, Woolhandler NEJM 1999, Hartz, NEJM 1989,
Devereaux, CMAJ 2004
For-profit hospitals – higher mortality
6% higher mortality in for-profit than
in private not for-profit hospitals
after controlling for severity of illness
and hospital characteristics.
Factors that improve survival
More board certified specialists
Higher payroll expenses/bed
Higher percentage of registered nurses
Data from 3100 hospitals: Hartz et al, NEJM 1989
Higher Mortality in For Profit Hospitals

9% > mortality in perinatal setting

2% > mortality adult care

Fewer skilled staff in for-profits
Meta-Review of 15 studies 26,000 hospitals, 38 million people

Devereaux et al, CMAJ 2002
Quality of care in for-profits ?
Study of 3558 hospitals showed lower quality care
in for-profits for myocardial infarction, congestive
heart failure, pneumonia
Jha, NEJM 2005
Study of 56% of all HMOs found for-profit HMOs
provided lower quality care as measured by
health indicators including: providing beta
blocker drugs after myocardial infarction,
providing eye exams for diabetics,
immunizations, pap smears, mammography,
psychiatric hospitalizations, pre-natal and post
partum care.
Himmelstein JAMA 1999
For profit = poor care
Patients in for-profit hospitals are
2.4 times more likely to suffer from
preventable adverse events
Thomas, et al, Int J Health Serv 2000
For profit psychiatric providers provide
lower quality care and less cost
efficient care than not-for-profits.
Rosenau, Psychiatric Services 2003
For Profit Care Costs More
For-profit hospitals cost more:
12%-15%
Silverman, NEJM 1999
3-11%
Woolhandler,NEJM 1999
15%
Meurer, Pediatrics 1998
$4,900 more per admission to rehab facilities
Woolhandler,NEJM 1999
Direct to Consumer Drugs ads = profits
DTC ads influence patient choices and increase
prescription volume
Mintzes CMAJ 2003
$1000 advertising linked to 41 new prescriptions for
cholesterol lowering drugs
Zachary et al, NHS 2001
Drug companies make $3.66 for each $1 spent
advertising blockbuster drugs Goscoigne, IMS Health 2004
Drug companies spend $3 Billion/year on DTC ads
supplemented by $6 Billion/year on marketing to
or “educating” doctors
Gilbody, QSHC 2005. Hightower, Hightower Lowdown 2012
Only US and New Zealand allow DTC drug ads
Most countries ban DTC ads because of problems
related to DTC advertising
Patients who request drugs after seeing ads are four times
more likely to be inconsistent with treatment guidelines.
Spence, Med Care Re Rev 2005
Advertising campaigns are strongest when new drugs are first
released. This can be dangerous even though clinical trials
have been successfully completed. For example, tegaserod
was heavily advertised for irritable bowel syndrome in
2006. Prescriptions rose 42% in English speaking Canadian
population exposed to these ads. Shortly afterwards, in
2007, the drug was withdrawn from the market because of
unanticipated cardiovascular risks.
Law, BMJ 2008
Physicians feel pressured to prescribe despite ambivalence
about appropriateness of treatment.
Gilbody, Qual Safety Health Care 2005
Convergent views of physicians
and the public regarding patient
safety and medical errors



Both underestimate the magnitude of the
problem.
Both ascribe more responsibility to
individuals than to systems – in sharp
contrast to the 2000 IOM report.
Both see nursing understaffing as a major
factor.
Blendon RJ NEJM 2002
Physicians views on possible solutions to problem
of medical errors
77% support requiring physicians to tell patients
when errors are made.
55% support requiring hospitals to develop systems
to prevent errors.
51% support increasing number nurses in hospitals.
46% support giving physicians more time to spend
with patients.
23% support mandatory reporting to state
21% support voluntary reporting to state
86% believe hospital reports should be confidential
and used only to prevent future mistakes.
Blendon, NEJM 2002
Physician perspectives on medical errors
Survey of 2637 US and Canadian physicians

64% see medical errors as serious problem
50% agree errors stem from systematic problems
(surgeons less likely to agree)
58% have disclosed medical errors

More support for disclosure among these groups


•
•
•
•
Believe that disclosure reduces lawsuits (1.58)
Not in private practice (1.47)
Canadian (1.43)
Surgeon (1.26)
Gallagher, Arch Intern Med 2006
Survey author Gallagher concludes

“In conclusion, the medical
profession should consider whether
the culture of medicine itself
represents a more important barrier
than the malpractice environment to
the disclosure of harmful medical
errors to patients.”
Gallagher, Arch Intern Med 2006
Patient perspectives
Want more time with doctors
See overwork and stress in providers
More nurses on staff improves care
See need for better communication
among members of health care team
Blendon NEJM 2002


Research validates these views
For example, MDs with more patient
centered communication order fewer
diagnostic tests.
Epstein AM Fam Med 2004. Stewart, Healthcare Policy 2011
Communication matters!
Pre-operative briefings
 Improve outcomes
 Prevent errors due to poor
communication
 Reduce nursing turnover
 Reduce costs
Lingard Arch Surg 2008. Lingard BMJ Qual Saf 2011. Haynes NEJM 2009
Nursing perspectives




Better staffing provides more job
satisfaction, scheduling flexibility and less
burnout and reduces errors.
While 13% vacancy rates are typical,
rising unemployment reduces vacancies.
15% of nurses are not working as nurses.
Working conditions more important than
money as factors leading to leaving the
profession: schedules, staffing,
communication, interpersonal issues,
respect.
Aiken JAMA 2002, RW Johnson, 2012
Nurse staffing and patient outcomes

Each additional patient added to a
hospital nurse’s workload is
associated with a 7% increased
probability of patient dying within 30
days of admission.
Record review: > 230,000 patients and
> 10,000 nurses
Aiken LH, Clarke SP et al, JAMA 2002
Market driven health care creates
conditions that cause errors




Staffing and Scheduling
Cost cutting
Hierarchical relationships that devalue
patients and health care staff
Seeking profits from situations where
there are great discrepancies in power
relationships
What is our main priority?
To provide opportunities for market
forces to exploit the sick and
vulnerable?
Or
To provide health care as a basic human
right?