Thursday, May 5, 2016

Are there really 250,000 preventable deaths per year in US hospitals?

For the last couple of days, the Twitter medical community has been discussing the latest in a long line of papers attempting to estimate the role of medical error as a cause of death.

This week's entry appeared in the BMJ (full text available here) and was by a surgeon at Johns Hopkins, Dr. Martin Makary, who claims that 251,454 patients die from medical error every year.

Makary's review extrapolated that figure from three papers published before 2009 which had a combined 35 supposedly preventable deaths. That's not a typo—35 deaths in all. One of the papers stated that all 9 deaths in three tertiary care hospitals were preventable. In his BMJ paper, Makary says, "some argue that all iatrogenic deaths are preventable."

I disagree. I have analyzed other papers on this subject and pointed out that certain complications and deaths are not 100% preventable. For example, no study of deep venous thrombosis and pulmonary embolism shows total efficacy of any prevention strategy. And some patients will suffer myocardial infarctions and die even when they are properly treated.

In this month's BMJ Quality and Safety, Dr. Helen Hogan of the Department of Health Service Research and Policy at the London School of Hygiene and Tropical Medicine discusses the problems associated with using preventable deaths as a measure of quality.

In the UK, 40% of deaths occur in patients over 80 years old and half of the people in the UK end their lives in hospitals. Hogan says "expected deaths as a result of underlying disease account for a large proportion of mortality, making it difficult to identify a signal of preventable deaths due to problems with care." When errors occur, it can be difficult to decide how much they contribute to the mortality of elderly patients.

Whether a death is preventable or not is often subjective and may depend upon the completeness of records and the "hindsight bias" of the reviewers.

The largest retrospective case record review done in England found that only 3.6% of deaths were preventable. Hogan writes "the vast majority of deaths do not involve quality problems [and] preventability of death is often difficult to determine."

Who dies in US hospitals? According to the Centers for Disease Control, about 715,000 people died in hospitals in 2010. Of those who died, 75% were age 65 and over, and 27% of in-hospital deaths were in patients 85 and over. The average age of patients who died in a hospital in the first decade of this century was 72 to 73.

Makary wants the CDC to start tracking medical errors. In a Forbes blog post about his paper, he said in an interview, “We need to insure legal protections so doctors can report accurately without repercussions.”

I laughed out loud at that. I don't think there is a doctor in the United States who would be stupid enough to write "medical error" on a death certificate for any patient.

About 18 years ago, The Institute of Medicine "called for a culture of confession" in its first report on medical error. So far, that culture has not materialized.

Makary co-authored a 2015 paper entitled "Early hospital readmission for gastrointestinal-related complications predicts long-term mortality after pancreatectomy." Hospital readmission within 30 days for gastrointestinal complications occurred in 128 (21.5%) of 595 patients who underwent pancreatectomy from 2005-2010, and 31 (29%) of those patients admitted within 30 days of their surgery died.

Did Makary or his colleagues write "medical error" on the death certificates of any of these 31 patients or were all of the deaths not preventable?

Medical errors do occur, and they should be identified and prevented. Makary's essay shines no new light, only heat, on the subject.


Cutter said...

Yet another example of sensationalist journalism, which seeks to foster paranoia and serves to undermine the trust of the populace in their healthcare system. I agree that medical errors do occur, and errors without impact to the patient are the most common type (and likely under-reported). Anybody want to attend a root cause analysis of why the antibiotic dose was 20 minutes late? Would that have stopped the patient from having a fatal heart attack?

The foolproof way to avoid surgical complications is to stop operating. By corollary, the best way to avoid dying in the hospital (where a medical error could occur), is to stay at home and succumb to your disease...

Skeptical Scalpel said...

Cutter, thanks for commenting. It is sensational journalism and faulty and irresponsible "research." By the way, I'm not the only one who said so.

Anonymous said...

The problem is that we can't get admittance for simple mistakes from the medical profession. This is why the "heat" is getting turned up. Without doing so, we can't seem to get buy in by admin.

matt_black said...

The medical profession clearly does have a serious problem with open admission of error (there have been plenty of arguments for moving to an airline industry style system where there are incentives to report mistakes and near misses so the system can improve.) Whether the numbers estimated by this paper are correct or merely sensationalist is a distraction from this sensible idea.

But it is wrong to dismiss all of the deaths in hospital as deaths that would have happened anyway. There are significant categories of error that are unambiguously avoidable. Hospital acquired infections or avoidable errors in prescribing for example. What is unclear is what proportion of the total this type of death represents.

And there is another category which may or may not be relevant: over treatment. Cancer patients who refuse aggressive treatment have much longer life expectancy than those who stay in hospital for aggressive interventions. Whether these are counted as "avoidable deaths in hospital" is moot. The statistics say that quality of life is harmed by what hospitals do. we don't pay enough attention that that either.

William Reichert said...

A few years ago when I was working in Atlanta, I led a weekly medical conference to present interesting cases for discussion.
To look for opportunities for "improvement" I decided to review all the autopsies done in the hospital and present the clinical situation on the interesting ones.One day I presented a man who had been seen by a cardiologist for dyspnea. The patient was begun on treatment for heart failure.
A week later he died and the autopsy revealed the cause of death
to be a pulmonary embolism. No one thought we should review any more autopsies after that revelation. We can learn a lot from our mistakes if we recognize them rather than bury them. But the hospital is NOT interested in this kind of self examination. They are more interested in advertising how great they are. Addressing medical errors interferes with this agenda. Too bad.

artiger said...

I'm inclined to agree, to an extent, about reluctance to admit errors in our care, but keep in mind we are getting squeezed by both sides in this. Patients and advocates want honesty and disclosure, while our legal counsels and insurers want us to be very careful about what we say and document. Perhaps that is where the pressure should be applied. Additionally, I think some events that are reported as errors are actually complications, and the two are not always the same thing.

Matt has a good point about overtreatment, and not just in cancer patients. Excessive transfusions, overutilization of X rays/CT scans and other diagnostic studies, unnecessary referrals, etc, all put patients at risk for errors and/or complications. Part of the problems there, though, is getting patients (or their family members) to buy into the idea that sometimes less is better.

Skeptical Scalpel said...

I was going to answer all these new comments but I think Artiger covered almost everything.

We will not get to the level of the airline industry until states make laws that protect doctors who admit mistakes. We are not anywhere close to that yet.

artiger said...

I apologize for the upstaging, but these studies have irked me to no end in two ways. First, by not clearly and correctly defining a medical error, and second by faulty extrapolation.

Fault us all you want for being egotistical and defensive (we have been), but don't produce crap research to prove it.

Anonymous said...

reply to matt black: "hospital acquired infections" are "unambiguously avoidable." You really know what you are talking about? Fat dude comes in with perforated diverticulitis and later gets an intra-abdominal abscess or a wound infection, and you claim that such infections are avoidable 100% of the time? Have you ever practiced medicine?
How do you propose that we keep granny from aspirating her gram-negative oropharyngeal flora and getting "hospital acquired" pneumonia? Perhaps we should tie off her trachea? Has it ever occurred to you that she needs to breathe?
Most hospital acquired infections come from the patient's own flora: so, do you propose that we autoclave our patients?

Skeptical Scalpel said...

I forgot to mention the unambiguously avoidable infections. Of course the anonymous commenter above is correct. It is impossible to prevent all wound infections no matter what antibiotics you use or how meticulous your technique is.

Jack Reacher said...

1) that paper should not have been published. Methodology is very doubtful, and makes me wonder how it has passed peer reviews
2) All good practionners are well aware of the risk each exams and treatment has, as they all have side effects. Overuse and also underuse of a treatment can lead to death (ie. Chemo). Normal use at the right dosage can also lead to death, since each individual is a variable.

3) the other problem lies in the diagnosis. Getting the right diagnosis is no easy task, we can only make a very educated guess. With experience we get better, but getting it 100% is just pure idealism. Even in the fictional world of house md, he doesn't get it right, not in the first time anyway.

Dr. Rob Oliver Jr. said...

In the absence of individual reviews of deaths with autopsy/toxicology trying to come with numbers is just a poor display of statistical misapplication.

As noted, patterns of death suggest that patients often die with complications rather then directly FROM complications.

Skeptical Scalpel said...

Jack and Rob, I agree. It's hard to believe it was peer reviewed.

David Gorski said...

Well, for one thing, it wasn't a study. Rather it was a commentary. I'm guessing peer review is less rigorous for commentaries. What was infuriating was how the press reported this as though it were a new study. It wasn't a primary study. It didn't add any new knowledge to the medical literature. It was just an extrapolation from four old studies.

Skeptical Scalpel said...

David, thanks for commenting. I agree it's not a study and certainly added nothing new. I kept trying to find the right word to describe it. That's how I came up with "essay." Commentary works too.

Anonymous said...

We are our own worst enemies in medicine. This paper was published not on merit but to fulfill an agenda. Most of our medical societies' statements and guidelines are more political than medical. The AMA completely caved to the ACA without a whimper. They were bought and paid for. When our President slammed surgeons for getting paid $75,000 to do an amputation no organization spoke up and said he was off by a factor of 100. It is pure arrogance and self delusion to think that every complication is preventable. Physiology and pathology dictate that is impossible. Unfortunately, we are now buried under unrealistic performance measures that sometime have no clinical merit whatsoever (e.g. VAE/VAC). I don't even see this ending and people wonder why physicians are often bitter and cynical. Welcome to medicine in the 21st century, where documentation in the chart is more important than what actually happens to the patient.

Skeptical Scalpel said...

I agree with everything you said.

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