Download - Hserv 482 #7 Medical Care and Health
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Hserv 482#7 Medical Care and Health
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WARNINGAttending this presentation
may be dangerous to your perceptions of health care
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Learning ObjectivesAnalyze a study suggesting that medical care
improves life expectancy
Present the data on medical harm in the US and other countries
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Experiences with health carePersonal experiences
– Family– friends
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How could one study the effect of medical care on health?
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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
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http://ucatlas.ucsc.edu/
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Sagar BU 2005
Health Care Insurance Profits $100 billion (2005)
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Sagar BU 2005
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Effect of antibiotics?
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Wilson 2005 IJE
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Vaccinations?
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JAPAN?
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Spend more money on health care?
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Scientific Study
Medical care has the capacity to improve mortality and quality of
life
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Bunker Paper looked at benefit of medical care & preventive services
on average life expectancy has increased from ~45 to ~75 years in rich countries
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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?
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Could medical care cause harm?Personal experiences
– Family– Friends
How would you study medical harm
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Medical harmMistakes
Adverse or bad outcomes, – No mistakes made
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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
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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)
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ADVERSE EVENTS: 3.7% of admissions
1/4 were result of negligence
Harvard Malpractice Study
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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
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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
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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
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Phillips 1998
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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”
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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
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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
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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 ?
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Doctorspublic
discount medical harm
ideas
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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)
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Kaiser Poll 2004
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Kaiser Poll 2004
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Kaiser Poll 2004
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Kaiser Poll 2004
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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.
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Are there aspects of health care that are beneficial?
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Role of Primary Care
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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
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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
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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?
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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.
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Woolhandler et. al. 2002
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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