Okay. Here we go.
I started by searching “third leading cause of death in america.” One of the first websites that returned was The Healthy Skeptic. It references an article called “Is US Health Really the Best in the World?” authored by Barbara Starfield MD MPH and published in the July 23, 2000 issue of JAMA. Turns out that most of the references to healthcare being the third leading cause of death in the US trace back to this article.
In the article Starfield highlights the following numbers (bulleted below) which are estimates of “the combined effects of errors and adverse effects that occur because of iatrogenic* damage not associated with recognizable error.” My interpretation of that sentence is that these numbers detail both deaths which have been specifically attributed to and documented as errors (doing the wrong thing) and deaths in which an outcome perceived as avoidable resulted from a medical intervention.
• 12000 deaths/year from unnecessary surgery
• 7000 deaths/year from medication errors in hospitals
• 20000 deaths/year from other errors in hospitals
• 80000 deaths/year from nosocomial infections in hospitals
• 106000 deaths/year from nonerror, adverse effects of medications
So the most interesting part there is the deaths perceived as avoidable. One assumes that an error has clearly defined criteria (although we might be surprised) but how does “could have been avoided” get defined and how is data collected? One of the great things about medical journal articles is that they reference each other. So one of the first things we’re going to do is see what we can understand about where these numbers come from.
The statistic of 12,000 unnecessary deaths per year comes from an article titled “Unnecessary Surgery” written by Lucien L Leape and published in the Annual Review Public Health in 1992, issue 13. In the first part of the article he defines an unnecessary surgery. I’m going to include the full paragraph because it mentions a specific example and I think the example is helpful to understanding how usefulness in this context is often tied to research evidence.
In contrast, Webster’s definition of unnecessary, “useless,” is easy to use, as it can be based entirely on objective data. No operation is necessary if it is ineffective, i.e. if it does not accomplish its objective for a given clinical situation.(1) For example, if the objectives of coronary artery bypass graft (CABG) surgery are to relieve pain and prolong life, CABG is ineffective and, therefore, unnecessary-for an asymptomatic patient with coronary artery disease that causes blockage of only one of the three coronary arteries, because studies have shown that CABG does not increase longevity in patients with single vessel disease. An unnecessary operation, then, is one that is ineffective or useless. An operation is also unnecessary if it confers no clear advantage over a less risky alternative. In both instances, the operation does not represent a net benefit to the patient. The patient will not be better off. This is the definition we will use.
(1) Rarely is an operation totally ineffective. Internal mammary ligation for the treatment of angina pectoris and glomectomy for asthma are examples. These operations were ultimately discredited by randomized trials. More commonly, an operation is effective for its initial use, but as experience is gained, the indications are broadened to conditions for which it is useless.
Leape goes on to say that unnecessary is also defined at a moment in time. A surgery that right now is thought to be necessary because there are no other options or because enough data hasn’t been collected might come to be seen as unnecessary in the future. Of course we can’t classify interventions by future information that can’t be known, but it is an important nod to the dynamic nature of medical knowledge.
Having defined unnecessary surgery, Leape turns his attention to the question of data collection which gets to the issue of assumption. When someone dies, we have no established system for pausing to reflecting on all the moments that lead up to this one and collectively deciding if there was a moment when a different decision might have lead to a different outcome. There isn’t time for that. If the moment was a true error – the wrong medication or the wrong amount of medication or the wrong surgery – it will likely get noticed and recorded. But all the other decision moments, the choice to recommend a surgery instead of another less invasive intervention or the use of one medication over another that caused an adverse effect that wasn’t predicted, those often pass with little reflection and are not recorded in a consistent manner across the country. So researchers do their best by looking at all the data we do have and speculating about relationships between that data to build an argument, in this case, about unnecessary surgeries.
For the next post, I’ll go into the evidence Leape presents to build a case for capturing data about unnecessary surgery. Stay tuned…
*Iatrogenic means “of or relating to illness caused by medical examination or treatment.”
8 Comments
http://www.theatlantic.com/magazine/print/2010/11/lies-damned-lies-and-medical-science/8269
The article above relates the relativity that is inherent in medicine. The reality is that other societies accept as fact. We on the other hand develop complex, treatments, declare them the standard of care, and make them the norm.
I think that another reason American health care costs are so high and American iatrogenic mortality may be so high is that we believe in what we read. We believe in the science behind our medicine. We have academic medical centers which are huge research establishments which spew out articles, reviews, textbooks, and conferences.
In Canada, where I trained, we had medical schools for education and hospitals. We read the literature much more skeptically. Our conferences were spartan with basic presentations and reviews of the practice of medicine. The emphasis was on getting the basics right. Doing things as simply as possible, etc. Letting patients die. I remember the frequent line of advice: “We are not in the business of the prevention of death.” “We are not here to give patients health.” We intervened where we felt conservatively our intervention would be infective. We spent huge amounts of time at the bedside watching the patient like hawks not to miss anything. This precluded the need for many imaging and other interventions.
I also trained in a historically Scottish hospital which was frugal, egalitarian if clannish, and practical. You really had to show that something worked before you did it.
Doctors were willing to walk away from very high risk surgery simply because they thought the odds were that the patient was better off without it than with it. I am an internist.
A fundamentally different style of the practice of medicine.
American physicians might consider us guilty of omission in some cases while we thought American physicians committed sins of commission. An American patient is likely to leave a doctor’s office with a new treatment. In a Canadian Scottish hospital, the patient might more often leave with reassurance or with advice to return as warranted.
We believed in the “tincture of time”. That is we believed in the self healing abilities of the body and were willing to watch and nudge the body along. American doctors would want to heal the body themselves or seemingly cure the patient with a definitive treatment.
Thank you for this in-depth look at this statement. The uselessness of such a definition of “useless” and “unnecessary” can be shown when the given definition of “useless” is applied to the surgery I do – cancer surgery. The objective of cancer surgery is to cure the patient of the cancer the patient has. In all cases in which the patient dies of the cancer being treated, the surgery was useless – 10-30% of patients so treated. Of course, the problem is that the “useless” procedure can not be identified before it is used. This same basic argument is being used for “end of life care.” Since the objective of identifying “useless” procedures is to avoid them, and such an objective can not be achieved, the process of identifying “useless” procedures is itself useless, if one uses such a definition.
The fallback position of these denigrators then becomes “evidence based practice.” However, cost/benefit analysis and other evidence based concepts are helpful for the physician and patient to decide on which alternative to choose. These concepts are being increasingly used to allow others besides the patient to decide the fate of the patient.
We are getting into some very tough questions here that can become very heated very quickly.
There are specific guidelines for surgery (curative and palliative) in lung cancer. These exist for a sound purpose. These are based on a variety of clinical and other factors. We followed them to a teee in Canada at McGill. On the other hand, I have seen Canadian trained surgeons violate those rules in the USA. Is that honest when there are forty million people uninsured and do not have access to care and to surgery that is actually curable? Doing questionable surgery (overpromising) when other patients would benefit from curative surgery. Is that good policy? What about the necessary suffering and futility of the 70% to 90% of patients who will not benefit from the intervention?
In the USA in terms of patient interest, many medical centers did bone marrow transplantation in women with later breast cancer. Did that work? What was the net benefit of that? But women wanted it. Patient desire does not prove efficacy.
The patient lying in bed terrified of their disease is not clearly the best judge of his/prospects or what will help him. He knows less of what will cure him. He is not an MD.
Clearly, also there is fundamental asymmetry between the doctor and the patient. The doctor is cool, calm and collected. He is clinical. He knows all the information and how to present it. There is always a chance. He can play on that. He may have student loans to repay. He may have college tuitions to pay for his children. He can make more money if he performs the surgery. So, he is not necessarily objective. Asymmetry of knowledge does not lead to market based good results. Professor Arrow, a leading economist, demonstrated that a generation ago. In addition, under current guidelines the patient is not paying for that surgery.
In the UK, primary care doctors will control the budget. The surgeon will have to persuade the PCP that the surgery is necessary and that it will help the patient. The PCP should be a neutral compassionate and informed Solomonic judge. He can understand what the surgeon is going to do and what the chances of success are.
At the Mayo Clinic, the surgeon is not paid more if he is more aggressive and that leads undoubtedly to less aggressive but more circumspect surgery.
Cancer and death are challenging. Surgery is not the straightforward solution that it is made out to be. Where has radical mastectomy gone? We have to improve our knowledge via hard earned and thoughtful scientific inquiry.
Bohdan A Oryshkevich, MD, MPH
A 1995 report by Milliman & Robertson, Inc. concluded that nearly 60 percent of all surgeries performed are medically unnecessary, according to Under The Influence of Modern Medicine by Terry A. Rondberg.
The death rate in each state would vary. But there are some countries very high mortality rate. This indicates that the level of health is less, and this should receive serious attention from the government. Thanks ~ Urinary System
This is certainly an article to be read! Very nice job
of research and expression! I think people will find
this topic to be interesting and appealing! As well as
informative, of course! Thank you for this fine read and
for sharing it online! Kind Regards!
Perhaps with the technology we have today a better data collection system can be devised to gather pertinent information and reduce unnecessary surgeries, complications and errors in the future. self help improvement
It is unbelievable that there are 20,000 deaths from errors in hospitals. As this is vague I would like to know the number of deaths from wrong diagnosis of conditions, particularly heart conditions. A company in Northern Ireland has just developed a breakthrough heart attack test which can diagnose symptoms far earlier than traditional methods. It is set to save thousands of lives each year.