Wednesday, June 25, 2014

1 in 5 elderly U.S. patients injured by medical care (or not)

A recent paper in BMJ Injury Prevention found that almost 19% of Medicare beneficiaries suffered serious adverse medical events (AMEs), 62% of which occurred from outpatient claims. Not surprisingly, poorer health, more comorbidities, and impaired activities of daily living were associated with higher risk.

Over 12,500 patients were surveyed and their Medicare claims were analyzed. Nearly 80% of patients who did not experience an AME survived to the end of the study compared to 55% of those who had AMEs. Statistical significance was not mentioned, and confidence intervals and p values were not stated.

The authors concluded that AMEs should be avoided because of the excess mortality and costs.

It is hard to argue with that, but as is true of many papers like this, the terminology changed in the body of the paper. An article about it quoted the lead author, a gerontologist, as saying, "These injuries are caused by the medical care or management rather than any underlying disease." Thus, AMEs became "injuries."

In the methods section, the authors list all of the ICD-9-CM codes included in the study.

Some of the codes are clearly preventable medical errors such as 997.02 Iatrogenic cerebrovascular infarction or hemorrhage, 998.2 Accidental puncture or laceration during a procedure, not elsewhere classified, 998.4 Foreign body accidentally left during a procedure, 998.7 Acute reaction to foreign substance accidentally left during a procedure, and the codes E870-867 "misadventures."

However, many may or may not be preventable like 997.1 Cardiac complications, not elsewhere classified, 997.31 Ventilator associated pneumonia, 997.41 Retained cholelithiasis following cholecystectomy, 998.00 Postoperative shock, unspecified, 998.30 Disruption of wound, unspecified, 998.5 Postoperative infection not elsewhere classified, and 998.83 Non-healing surgical wound.

A series of codes, E930–E949, comprises adverse drug events, most of which are not preventable.

The numbers of patients with each specific complication were not provided.

This did not stop medical news media from proclaiming more doom and gloom.

HealthDay: "1 in 5 Elderly U.S. Patients Injured by Medical Care"
WebMD: "1 in 5 elderly patients injured by medical care"
Today Topics: "Medical injuries affect almost one in five older adults in receipt of Medicare"

It is impossible to conclude from the data that all of these AMEs were caused by "medical care or management." You can quibble about whether some complications are preventable or not, but the percentage of preventable AMEs is far less than 19%.

And how many more deaths would have occurred had the patients not been subjected to "medical care or management"?

I wish people would stop writing these kinds of papers and ease off on the sensationalist reporting of them. But I guess if they did, I would have less to write about.


artiger said...

I don't wish you had less to write about, I just wish you had more positive things to write about.

Sensationalism sells. Remember that Don Henley song, "Dirty Landry"? He didn't call it "Clean Laundry" for a reason.

Anonymous said...

I think the issue is the fact that the medical community doesn't do anything but deny and defend rather than openly saying you have problems and how to fix them. Most people can spot a sue happy nut. There are many (myself included) who would have been happier that the doctor fixed the problems, was educated, and basically acted like a responsible, respectable human being for doing the right thing.

Lets face it: I've seen a lot go wrong and the medical community wants to keep it buried rather than working with the patient communities to help fix things. I'm not talking about obvious Dr. Oz followers, I am referring to people like me who read UpToDate and other medical databases.

I've applied to be on the patient team at the hospital who hoosed me up. No response. So someone who has made suggestions (and yes, risk management acted on them) and then tossed aside, no thank you and basically screw you, this is why you see the things you do.

dr morasca said...

sadly I still find that there are many who do not appreciate the difference between a bad decision and a bad outcome from a proper decision. I have not seen the above studies details but I have reviewed many that are similar and have found they are conspicuously lacking in the details over whether or not the medication in question was given for the proper indication. This would make a critical difference in the analysis in that a proper medication given that turned out a bad outcome cannot be foreseen and should not be considered and medical error.

Karen Sibert MD said...

Here's another piece in The Healthcare Blog that similarly confounds HACs with injury:

Skeptical Scalpel said...

Thank you for commenting.

Dr. Morasca, I agree with you. What people who are not clinical MDs do not understand is that sometimes in the middle of the night when you are juggling a few sick patients, you have to make decisions. Even the right decision will not always prevent an adverse outcome. And some meds produce adverse outcomes, but not treating a problem can give you a bad result too.

Karen, I appreciate your citing my post in your comment on that Healthcare Blog. It is so frustrating to me that many people equate a complication with a mistake. I will continue to point these things out until it stops happening.

Libby said...

"The authors concluded that AMEs should be avoided because of the excess mortality and costs." I dunno, (dripping with sarcasm) maybe they should be encouraged in order to loosen up more beds for those waiting in the ED. Soooo, if people didn't die and it was cheap to leave stuff inside people during operations then it would be ok? Sometimes humans say really strange things. Like, "drive safely" like the person was planning on driving blindfolded.

I agree, somethings happen dispite our belief that an intervention/treatment would be the best option in that particular instance. I certainly hope MDs don't wake up every morning and say "gosh, it's a good day to screw up and kill off someone".

Keep writing Dr. S. I learn from you and your commenters. Odd how I see more now during my volunteer shift in the ED from reading your blog. In a good way.

Skeptical Scalpel said...

Libby, thanks for the comments. I'm glad you saw the stupidity of the authors' conclusion. Research like this drives me crazy.

Anonymous said...

Another wonderful example of correlation = causation in the media.
Take only med errors, for example.
A person getting 10 meds is more likely to rack up a med error than someone getting 1 or 2.

Too often, media outlets look at the data later and say "the people with medication errors had worse outcomes!" - but neglect to look into whether the population most likely to suffer med errors (those with multiple meds managing multiple problems) had worse outcomes as a whole, aside from any error.

Skeptical Scalpel said...

That's an excellent point. If you take a lot of meds, you are sick. If you take a lot of meds, an error is more likely. I wish I had thought of that.

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