Hserv 482
#7 Medical Care and Health
WARNING
Attending this presentation
may be dangerous to
your perceptions of health care
Learning Objectives
Analyze a study suggesting that medical care
improves life expectancy
Present the data on medical harm in the US and
other countries
Experiences with health care
Personal 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/
Health Care Insurance Profits $100 billion (2005)
Sagar BU 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
SUMMARY
Health 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 harm
Mistakes
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)
Harvard Malpractice Study
ADVERSE EVENTS:
3.7% of admissions
1/4 were
result of
negligence
ADVERSE EVENTS (3.7% ):
- 19% of adverse effects drug related
- 14% wound infections
- 13% complications from technical procedures
Brenna n et. al. NEJM 19 91
DEATHS
13.6% of adverse events
over half (51.3%) the
result of NEGLIGENCE
Brenna n et. al. NEJM 19 91
Conclusions
Getting 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 preventable
Varying terminology:
– US: errors, mistakes, negligence, iatrogenic injury, substandard care
– Canada, NZ, Australia, UK, Denmark: preventability
– Australia: human error
ACLS Professional Provider Manual
Epinephrine "Although epinephrine has been used for years in resuscitation,
there is little data to show that it improves outcomes in humans" pg 49
Lowest Life Expectancy
And disability free years
Highest Life Expectancy
And disability free years
Life expectancy disparity
is 16 years
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 STRIKES
Bogota 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.
and
Nov/Dec 2005
(% pts ≥ 1 AE)
% AEs
Prevent
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
0.6/1000
days
9
35
~.1 per
adv ev
?
Medical harm Olympics
France (2004) prospective
Denmark
Prevalence
40
Doctors
public
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 Care
Easy 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 Coverage
Political 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?
“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.”
Web of Influence
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