Heartland Health Research Institute

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Another Estimation on Hospital-Related Deaths Due to Medical Errors

Another Estimation on Hospital-Related Deaths Due to Medical ErrorsJust one year ago (February 2016), Heartland Health Research Institute (HHRI) published a series of white papers, ‘Silently Harmed – Hospital Medical Errors in the Heartland.’ ‘Silently Harmed’ was intended to demonstrate what the national estimated preventable adverse events (PAEs) may mean to Iowa and six states contiguous to Iowa. Using a handful of U.S. studies that evaluated preventable mortalities, HHRI settled on approximately 250,000 patients dying annually in U.S. hospitals due to preventable mistakes.

Just two months after ‘Silently Harmed’ was published, The Leapfrog Group estimated over 206,000 avoidable deaths occur in hospitals annually. A month later in May, a report released by Makary and Daniel estimated preventable deaths in U.S. hospitals to be greater than 250,000, similar to the HHRI estimate. The Makary-Daniel report made national headlines by suggesting “medical errors are the third leading cause of death in the United States.”

Another report has now been released in the March 2017 edition of the Journal of Patient Safety suggesting that “approximately 200,000 preventable hospital-related deaths each year in the United States is not unreasonable.” This report is authored by Kavanagh, Saman, Bartel and Westerman.

Unfortunately, there are no systematic protocols in place within our hospitals that mandate reporting medical errors. To date, all studies that address the mortality in U.S. hospitals due to medical errors are simply projections that are based on small sample sizes of hospitals and patients. The provider community, armed with their own under-reported data on medical errors, can only argue that these estimates are much too high. The fact is that much of the literature suggests that these estimations are conservative and underestimated.

What I found to be most interesting in the recent report by Kavanagh et. al include the following:

  1. Patient Perspective – Any insinuation from the medical community that preventable medical errors should be discounted due to patient age, health or life choices are baseless. If a terminal patient dies prematurely due to a medical error, this is still an unacceptable occurrence. As the article correctly states, “Medicine does not have the moral authority to discount or disregard days, weeks, or months of life.”

 

  1. Voluntary and Non-Audited Reporting – Voluntary and non-audited reporting mechanisms greatly under-report adverse events, preventable harm and fatalities. “The 2010 Office of Inspector General Report found diagnostic codes ‘absent or inaccurate’ in seven of eleven Medicare hospital-acquired conditions, and in 93 percent of the time, incident reports were not submitted.” In fact, “since 2005, an average of less than 1000 sentinel events have been voluntarily reported to The Joint Commission per year from the hospitals that have undergone their accreditation process…Officials at The Joint Commission estimate that less than 0.1% of events have been reported.”

 

  1. Cultural of Safety – Having a ‘culture of safety’ serves as the hospital’s foundation from which to build new internal systems and policies that prevent patients from being harmed. “What ties the occurrence of preventable adverse events and mortality together is the willingness and determination of facilities to adopt a culture of safety and invest in patient safety. The adoption of preventive protocols is further hindered by the United States’ fragmented, nonuniform healthcare systems composed of facilities with differing philosophies and administrative structure.”

 

  1. Put Your Money Where Your Mouth Is – Some in the healthcare industry ignore current studies on medical harm and believe we must wait for more perfect data before it can be shared with the public. “The onus should not be on consumers but on the healthcare industry to generate comprehensive data to demonstrate that their product is safe.”

 

One example on just how grossly under-reported adverse events are in our hospitals, just look at a recent article in the Minneapolis Startribune. The article indicated that Minnesota hospitals reported only 336  ‘adverse events’ during the last year, including operations on the wrong body parts and disabling medication errors. The report included four adverse events that resulted in deaths — three from patient falls and one from a medication error — and 106 that led to severe injuries. This type of reporting runs contrary to national reports on adverse events in U.S. hospitals. In May 2016, the Agency fo Healthcare Research and Quality stated, “According to the most recent data, nearly 4 million adverse events occurred in U.S. hospitals in 2013…we can project that about 170,000 people died in 2014 as a results of an adverse event or medical error.” This estimate is for Medicare-eligible patients only. Based on 585,000 hospitalizations in Minnesota in 2012, HHRI estimated that roughly 146,000 patients are seriously harmed in Minnesota each year, while over 4,200 patients are fatally harmed annually.

Creative reporting of such important metrics continues to be allowable in this country.

Most agree that we need better data to avoid further speculation of this epidemic. Playing horseshoes and hand grenades to determine the number of patients harmed is no longer good enough. After all, if we don’t know the extent of the problem, how can we determine whether the new delivery and payment systems will solve it?

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Healthcare Waste – It’s About Priorities and Opportunity Cost

Healthcare Waste - It's About Priorities and Opportunity CostWe know that healthcare spending continues to grow at an unsustainable rate. Each election cycle, we expect policy makers to find meaningful ways to slow that growth and ultimately reduce spending – while maintaining quality and access.

As mentioned in our previous blog “Time to Move Upstream and ‘Invest’ in our Health” co-authored with Dr. Yogesh Shah, the prudent approach is to simultaneously move upstream and address the social determinants of health. This thinking might sound ‘pie in the sky’ to some, but controlling costs cannot happen without addressing the environment in which we live, learn, work and play.

In addition, there is another culprit that must be eliminated – healthcare waste. If we are successful in eliminating this waste, by most national estimates, we can reduce our costs by 18 – 40 percent. The midpoint of waste is about 30 percent of healthcare costs.  Per the Robert Wood Johnson Foundation, this waste comes in many different categories:

  • Failures in Care Delivery – poor execution or lack of widespread adoption of best practices, including effective preventive care practices or patient safety practices.
  • Failures of Care Coordination – Fragmented and disjointed care of patients when transitioning from one care setting to another.
  • Overtreatment – Care that ignores scientific findings, perhaps due to outmoded habits. Defensive medicine is an example, such as unnecessary tests or diagnostic procedures to guard against malpractice lawsuits. Here is just one example.
  • Administrative Complexity – Having multiple ‘administrators’ with divergent protocols and practices, such as the government, insurance companies or accreditation agencies who create inefficient and overly bureaucratic procedures.
  • Pricing Failures – This waste is baked in to our healthcare ‘system’ because the price of a service exceeds what would be found in a properly-functioning marketplace. In healthcare, we lack appropriate competition at the right levels and have little transparency on cost and outcomes.
  • Fraud and Abuse – This is the cost due to fake medical bills and scams, in addition to the cost of inspections and regulations to thwart any wrongdoing.

Iowa Healthcare Component Costs

Based on the population of 3.033 million Iowans in 2009, the cost per capita in Iowa for healthcare was $6,921, totaling almost $21 billion. The largest portion of this cost comes from hospital care, which consumes about 39 cents of every dollar spent on healthcare ($2,713 per capita). This amount includes the total net revenue (gross charges minus contractual adjustments, bad debts, and charity care). Assuming the midpoint waste average in Iowa is 30 percent, and we have little reason to believe it is measurably different from national norms, the total annual amount considered to be wasted on hospital care would be $814 per Iowan.

Using a similar waste factor of 30 percent for each of the nine health components, the total waste per capita would amount to $2,076 (see graph below). Because many of the components are interconnected with one another, it is extremely difficult to cull out the actual waste factor within each component. Some components may have much lower inherent waste, while others may not. Costs such as insurance program administration, research and construction expenses are not included.

Iowa Healthcare Cost Per Capita

The following graph provides the total healthcare costs (in $) for each of the nine components, in addition to the potential wasted spending. Again, using hospital care as an example, if 30 percent of waste was eliminated in Iowa hospitals, the price tag could have dropped from $8.2 billion to $5.7 billion – resulting in a $2.5 billion ‘savings’ – or unnecessary overpayment.

Healthcare Costs in Iowa - 2009

Healthcare Waste of $6.3 Billion

I share this information for a reason. Much like the individual choices made daily in our lives, there are opportunity costs for the choices we make, or fail to make. The notion of opportunity cost plays a crucial role in attempts to ensure that scarce resources are used efficiently. If the midpoint assumption of 30 percent waste occurs in healthcare delivered in Iowa, then overspending $6.3 billion annually (and growing due to increased costs) is a huge opportunity cost for Iowans. Think about it, what other ‘opportunities’ can we invest in and receive much better ‘returns?’

Most Americans detest waste – especially when it affects our pocketbooks and the potential impact it has on our health and well-being.

Waste is anything that doesn’t add value to the end product. In manufacturing, waste can be rooted out by using different proven programs, such as lean manufacturing. Doing so allows the manufacturer to build higher-quality products at a more competitive cost. The same process can be used in healthcare. Having the right kind of incentives to change the willpower and behavior of those providing (and paying) for this care, is crucial.

Community Needs in Iowa

In Iowa, communities have a myriad of health needs that go unmet, but most often have limited resources to address these problems. According to Mid-Iowa Health Foundation’s website, there are many community needs for our youth that require attention and affect the social determinants of our health and well-being:

  • 20 percent of children in Iowa lack adequate food
  • Roughly 7,000 school age children in Iowa are homeless
  • Over one-third of Iowa fourth graders read at or above the proficient level
  • Over 13 percent of youth in Iowa are exposed to drug use in their home
  • Approximately 12,000 children are victims of abuse and neglect
  • About 10 percent of central Iowa children say they do not live in a happy home
  • Almost 13 percent of Iowa youth had serious thoughts about killing themselves in the last year
  • More than 20,000 children are living below the poverty level in Polk County
  • 80 percent of Iowa children with mental health needs never receive treatment
  • Only 45 percent of youth in the Des Moines community are hopeful for the future

 

This list represents just a small sampling of social determinants that eventually affect the healthcare we pay. By smartly eliminating waste in our healthcare system, and thoughtfully re-directing the ‘savings’ in areas that matter most to our communities, we can further stem our healthcare-cost epidemic. Imagine the sizeable dent we make in our communities by culling out billions of dollars annually from the waste we pay. The discussion of displaced healthcare jobs and the potential ‘economic impact’ requires further exploration in a later post.

Following the election, we will continue to debate the fate of Obamacare – who will pay and how much – but this discussion is being made with greatly inflated dollars. We would be well-served to dedicate equal energy to squeeze the waste from healthcare and redirect resources to benefit our communities.

We know the waste is there. But what about our willingness to eliminate it?

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Time to Move Upstream and ‘Invest’ in our Health

Time to Move Upstream and 'Invest' in our Health

Authors:  David P. Lind and Yogesh Shah, MD, MPH

Employer-sponsored health premiums in Iowa have increased 215 percent since 1999. This growth, however, appears tame when compared to health insurance plans sold in the individual market. We’ve grown so accustomed to rising health costs that it has become the ‘new normal’ with no apparent silver bullet in sight to remedy the core problems. Healthcare costs continue to outpace general inflation, typically by two-to-three fold. We live with constant anxiety about paying more for our healthcare – whether through taxes, premiums, deductibles and/or other out-of-pocket expenditures.

With the advent of a new Trump administration geared to repeal many Obamacare components, all sorts of health insurance “solutions” will be debated. Ideas to make coverage more competitive include selling policies across state lines, pushing for health savings accounts, and relying on other tax incentives to perform magic. However well-intentioned, belief that the insurance component will somehow fix our cost problem is wishful thinking.

The major source of this problem is our unhealthy population. “Upstream” environmental factors greatly impact our “downstream” health. for all of us. Upstream factors are many – primarily poor nutrition, inadequate housing and education, and low incomes – all considered to be social determinants of our health.

To meaningfully address healthcare costs in Iowa and nationally, we must be willing to consider new approaches and develop a mindset that transcends party politics. This may sound counterintuitive, but to reign in ever-increasing healthcare costs and enhance better population health, we should explore new solutions ‘upstream’ to invest in our collective health and well-being. This is not about implementing ‘socialized medicine.’ It’s about using our limited resources more wisely on key determinants of overall health that can ultimately improve health and control healthcare costs.

Healthcare Spending

In 2014, we spent 17.5 percent of our economy on healthcare, reaching $3 trillion annually. By comparison, in 1960, we spent only five percent on healthcare. One disturbing estimate by the Institute of Medicine shows about one-third of our healthcare spending – or $1 trillion – is widely considered wasted spending, money that can be better invested elsewhere.

Should healthcare costs dominate such a large segment of our economy? If so, shouldn’t we be healthier than other nations based on what we spend? On a per capita basis, the U.S. performs poorly on many key health indicators. For example, our country has lower birth weight, higher maternal and infant mortality, as well as higher incidents of injuries, obesity, diabetes, heart disease, chronic lung disease, disability rates, mental illness and, surprisingly, shorter life expectancy. In addition, we have more drug-related deaths than other industrialized countries.

With these in mind, one would think that most comparable countries must be outspending the U.S. on healthcare services. The facts are quite the opposite. In 2009, our country spent 16.3 percent of its gross domestic product (GDP) on healthcare, about six percentage points higher than the average 10.3 percent spent by 10 other industrialized countries. Yet, our growing appetite for more healthcare spending results in poorer health outcomes. This is both puzzling and frustrating – for policymakers, taxpayers, employers and their employees.

Time to Move Upstream and 'Invest' in our Health - Aggregate Health Care Spending by Country

Social Services (Community Health) Spending

Instead of focusing on how to pay for healthcare – a perpetually-growing segment of our economy – we should re-direct our limited resources to impact basic social determinants of health, such as targeting education, housing, nutrition and poverty. Unlike healthcare, U.S. public spending on social services falls far below other developed nations. In 2009, the U.S. spent 9.1 percent of its GDP for aggregate social services versus the average of 15.8 percent spent by all 10 other wealthy countries.

Time to Move Upstream and 'Invest' in our Health - Aggregate Social Service Spending by Country

When combined, U.S. healthcare and social services spending ranks in the middle of the pack of peer countries, with a disproportionately higher amount spent on healthcare than on social services.

Time to Move Upstream and 'Invest' in our Health - Aggregate Health Care and Social Service Spending by Country

The U.S. is the only wealthy country where healthcare spending accounts for a greater share of GDP than social services spending – an “imbalance” our country has embraced. Over decades, we’ve allowed soaring healthcare costs to smother the necessary investments we must make to improve our community health. In other words, our country inefficiently relies on medical care and insurance to address problems that we fail to address upstream, at their source. An insightful reference on this subject comes from a book written by Elizabeth H. Bradley and Lauren A. Taylor – The American Health Care Paradox…Why Spending More is Getting Us Less.

What can we learn from this?

High healthcare spending in the U.S. has far-reaching economic consequences, such as wage stagnation, personal bankruptcy and budget deficits. Extensive evidence suggests that making the right investments in social well-being substantially improves population health outcomes downstream. For example, housing vouchers, home energy assistance and the availability of supermarkets in low-income areas are known to reduce obesity, diabetes and nutritional risk in children. In addition, availability of prenatal and infant nutritional assistance is associated with reduced infant mortality.

Realistically, the American culture has had little appetite for becoming more ‘socialized’ in tackling upstream problems, relying instead on the national ideology that spending more on healthcare will solve our health woes and improve health outcomes. But for meaningful change to occur, balancing healthcare with social determinant strategies must emerge both nationally and locally here in Iowa. The Iowa Healthiest State Initiative, a nonpartisan, nonprofit organization, is just one example of attempting to improve the physical, social and emotional well-being of our Iowa communities. This initiative is a good start, but other bold private and public initiatives need to be undertaken for real positive change to occur in healthcare outcomes.

Investing in our health upstream makes a great deal of sense. Spending for the ‘right’ community measures that impact health will provide better health outcomes for Iowa and our country. Such expenditures will take time to translate into positive health outcomes but we need to start investing now. The result may be cost-shifting from inefficient healthcare spending to re-allocating funds for social determinants that matter most, such as nutrition, adequate housing and education. By doing so, we will make our communities and state both healthier and more productive.

Controlling health costs and improving population health – we cannot have one without the other.

 

Real Hospital Metrics We Need to Know

Real Hospital Metrics

Each year, about a quarter of a million patients are estimated to be fatally harmed due to preventable medical errors in U.S. hospitals. This mid-range estimate is used in our ‘Silently Harmed’ white papers and was recently reported in May by Dr. Martin Makary of Johns Hopkins. Given this startling (and probably conservative) number, here are a few critical (yet simple) hospital-specific, patient-safety culture metrics that would be helpful for the unsuspecting public.

Most often, these metrics are only available to specific participating hospitals and the Agency for Healthcare Research and Quality (AHRQ) – the federal agency whose mission is “to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable…”

The AHRQ sponsors the development of patient safety culture survey tools for hospitals, nursing homes, ambulatory outpatient medical offices, community pharmacies and ambulatory surgery centers. As an example, the hospital survey was designed to assess hospital staff opinions concerning patient safety issues, medical errors, and event reporting. Though not mandatory, these instruments can be used by hospitals and other providers to make the following assessments of their organizations:

  • Raise staff awareness about patient safety.
  • Diagnose and assess the current status of patient safety culture.
  • Identify strengths and areas for patient safety culture improvement.
  • Examine trends in patient safety culture change over time.
  • Evaluate the cultural impact of patient safety initiatives and interventions.
  • Conduct internal and external comparisons.

 
Since 2007, approximately 30 percent of U.S. hospitals have administered the safety survey to their doctors, nurses and other healthcare workers. Survey data is collected every two years. In order to trend their results over time using the AHRQ database, hospital-specific surveys may only be up to two years old. For the most recent survey year (2016), a total of 680 hospitals submitted data, comprising approximately 448-thousand hospital staff respondents.

Four answers worth knowing

As a prospective hospital patient, I would want to know what percent of surveyed staff members responded “yes’’ to the following four questions:

    1. Would you have your surgical procedure at the hospital (or the department/unit) in which you work?
    2. Do you feel comfortable speaking up when you have a safety concern?
    3. Does the teamwork here promote doing what’s right for the patient?
    4. Are your managers and administrators responsive to your patient-safety concerns?

 
In order to elicit honest responses from hospital staff, confidentiality is extremely critical. If staff members feel that confidentiality is lacking, the survey becomes a meaningless ‘gamed’ response and is possibly more harmful because the rose-colored results may mislead the public. If we, the public, had access to these comprehensive and revealing standardized results every two years, we would have an easier way to assess which hospitals are safer than others.

Think about it. Would you want to seek care from a hospital where only one-third of its staff would choose to go for their own care? By making choices that are important to you and your family, hospitals would be incentivized to invest in a part of healthcare (safe care) that has been grossly neglected for decades.

Teamwork = Effective Care

One cannot underestimate the importance of teamwork when seeking appropriate and effective care. Evidence of a safe workplace culture is present when each member within a specific hospital department or clinical area:

  • Is comfortable being a patient within that care unit.
  • Feels comfortable speaking up when there is a safety concern.

 
A well-coordinated team thrives on strong communication protocols. This culture-of-safety ensures that medical errors will eventually be reduced, much the way teamwork required in a cockpit is designed to reduce pilot errors.

Not all hospitals are the same. In fact, not all departments within the hospital are the same. It’s the teamwork culture-of-safety that exists and continues within each unit of each hospital that makes the difference. The right culture will be sustained despite the turnover that invariably happens due to retirement, job-changes, etc.

Hospitals (and their associations) often debate which metrics should be used to hold them ‘accountable.’ They cite many methodological reasons why such metrics should be avoided or embraced. Some of these concerns may be legitimate. But perfect is often the enemy of good. For me, simplistic answers to the questions above will ultimately determine whether the care we seek is what we were hoping to obtain.

There is nothing wrong with keeping it simple.

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Healthcare Costs and Wages in Iowa
the Faceless and Nameless Among Us

Healthcare Costs and Wages in Iowa - the Faceless and Nameless Among UsWhether it is a morning jog or perhaps a bike ride, I find great pleasure in determining the measureable progress I have made both in distance and time.

The same can be said about reviewing data from our past studies that cover a longer period of time. Doing so helps gauge a better understanding of trends occurring within benefits, specifically as it relates to health insurance components. As we are keenly aware, what we pay for our health insurance and the healthcare we receive continues to nip at take-home pay and the ability to afford other necessities, such as food, clothing, housing, etc.

A recent study commissioned by 25 local Iowa United Way associations indicated that for almost a third of Iowans (31 percent), the income they receive does not allow them to cover the basic costs of living. In fact, two parents working full-time in this state would need to collectively earn $23.34 per hour over a 40-hour week to cover basic household costs. With cities, counties and states debating what specific minimum wage amount should be acceptable (and affordable), this topic will not go away anytime soon.

Knowing that components of health insurance plans, such as premiums, deductibles and out-of-pocket maximums continue to push northward, this also impacts family budgets and whether they have adequate health coverage. By ‘adequate,’ I am referring to cost-sharing responsibilities that may overwhelm lower-earning Iowans. According to the Kaiser Family Foundation, Iowa happens to have a lower-than-average rate of uninsured (six percent). Nonetheless, even those who do have coverage continue to experience higher cost-sharing arrangements that may cause people to seek less care – which is a plausible reason we see moderation in the growth of health cost spending.

With this in mind, I want to take a quick look ‘back’ on trends for a few health insurance cost components confronted by Iowans with employer coverage. Covering a six-year period (2009 – 2015) from our annual ‘Iowa Employer Benefits Study©,’ we learn that the average weekly wage from the Iowa Workforce Development (IWD) rose annually by 2.6 percent, while premiums increased during that same period by 9.2 percent prior to any plan designs changes made to lower the increase. Altering plan designs typically result in higher cost-sharing for employees, something that employers are reluctant to do. After alterations, the average annual premium increase was 5.5 percent, still over twice the weekly wage increase.

In addition to premium inflation, Iowan’s with employee-only coverage have experienced increasing deductibles by eight percent annually, from $1,061 to $1,662. The total cost-sharing exposure Iowan’s pay for medical costs (e.g. out-of-pocket maximums) increased by 6.1 percent annually from $2,210 to $3,151. Finally, employees with single coverage have contributed 6.2 percent more annually through payroll deduction for their cost of the employer-sponsored coverage.

Here is a summary of the six-year history.

Average Annual Increase in Iowa (2009 –As payment responsibility for medical costs continues to shift from employers to employees, a new dynamic of patients becoming the ‘new payer’ profoundly impacts the receivables for the provider community, specifically hospitals. Though not new information, this fact can and will change how financing options may evolve from providers to help patients navigate their financial obligations and ensure that patients are well educated about the cost of their care. Insurance companies, for their part, may also explore innovative financial solutions to help their insureds assume payment responsibilities – possibly a foray into a new market of opportunities.

Trends found in this six-year period will most likely continue well into the future, and the evolution of how we pay for our healthcare will require off-the-beaten-path solutions to establish new funding mechanisms for an increasing number of patients.

Over time, the compounding of these trends will affect more Iowans, revealing that many will no longer be faceless and nameless, rather, they may become us.

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The Lure of Opioids

The Lure of Opioids

One medical topic clearly on today’s radar is the use (and abuse) of opioids – medications that are often used to relieve pain, such as: hydrocodone (e.g. Vicodin), oxycodone, morphine, codeine and other related prescription drugs.

It is relatively easy to become addicted to opioids. Like many others, I have been prescribed various opioids (typically Vicodin) in the past when having lower back pain or a dental procedure that required pain management. Thankfully, I used only a very small portion of the prescribed pills during each incident, which resulted in the accumulation of many ignored (and expired) bottles in our medicine cabinet.

For many, the continued use of opioids to control pain may quickly evolve into a habit, and eventually, addiction. Without seeking and receiving appropriate rehabilitation for opioid addiction, accidental deaths happen far too often. In 2014 alone, the number of opioid deaths due to overdose in the United States was 28,647, a number that exceeds the size of Marshalltown, Iowa’s 16th most populated city. A 14 percent increase from 2013, this number represents an age-adjusted rate of 9.0 Americans per 100,000.

Iowa Opioid Fatalities

The Kaiser Family Foundation analysis shows that 158 opioid fatalities occurred in Iowa during 2014. With an adjusted death rate of 5.3 Iowans per 100,000, Iowa ranks considerably below the U.S. average. The adjusted rates of fatalities per 100,000 for each of Iowa’s six neighboring states are listed below:

  • Nebraska – 3.2 (56 fatalities in 2014)
  • South Dakota – 4.1 (33)
  • Minnesota – 6.0 (318)
  • Illinois – 9.4 (1,205)
  • Wisconsin – 11.1 (627)
  • Missouri – 12.0 (696)

The below-average rates for Iowa, Nebraska, South Dakota and Minnesota leads one to ask, “What are these states doing differently?” Have these states implemented actions preventing individuals from becoming addicted and treating those who are addicted? Do they have narcotics detectives and emergency medical technicians who help guide individuals to treatment rather than arrest them? Some states have indeed implemented programs to address this emerging topic of national concern.

The Center for Disease Control and Prevention (CDC) recently released guidelines to help physicians prescribe opioids appropriately and responsibly. The opioid crisis should not just be the concern for providers who prescribe opioid medication. In fact, everyone has a role to play mitigating this epidemic, including those addicted and their family members, those who treat the addicted, educators, law enforcement agencies, and the efforts of a well-coordinated community. As two authors commented in a recent Health Affairs publication, the opioid crisis is “a multi-faceted problem [that] requires a multi-faceted solution.”

For each of us, a frequent reconnaissance of our medicine cabinets to ‘search and safely dispose’ is a good first step to eradicating opioid misuse and abuse.

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Codman – A Medical Pioneer

Ernest Amory Codman

Dr. Ernest Amory Codman

Henry Ford was one. So was Eli Whitney, Thomas Edison, and more recently, Steve Jobs. Each developed their own niche through new areas of thought, research and ingenuity and are now synonymous with the title, ‘pioneer.’

‘Medical Outcomes’ Pioneer

Another pioneer was a Boston surgeon by the name of Dr. Ernest Amory Codman. Unfortunately, his work was considered unpopular among his peers, so by the time he died in 1940, he had little fame or fortune. He died penniless without even a headstone on his grave.

Born in 1869, Codman made contributions to anesthesiology, radiology, duodenal ulcer surgery, orthopedic oncology, shoulder surgery, and the study of medical outcomes. But his biggest contribution was founder of what is known today as ‘outcomes management’ in patient care.

Codman became the first American doctor to follow the progress of patients through their recoveries. Using “End Result Cards,” he kept track of every patient he treated, along with demographic data, diagnosis, the treatment rendered, and the eventual outcome of each case. He would follow up with patients at least one year after treatment to determine the outcome of his work.

Unlike his peers, it was his lifelong passion to establish an ‘end results system’ to track patient outcomes. Clinical ‘misadventures’ would be identified and provide additional insight to improve the care of future patients. But this was not enough for Codman. He also believed that all information stemming from this work should be made public so that patients could make educated decisions on which physicians and hospitals to seek care.

This happened over a century ago!

While on surgical staff at Massachusetts General Hospital (MGH), Codman also became a member of the Harvard faculty and instituted the first morbidity and mortality conferences. MGH had little interest in Codman’s pursuit of health outcomes, and he subsequently lost his staff privileges. Not deterred, and exhibiting characteristics of a honey badger, Codman established his own hospital to pursue the performance measurement and improvement objectives he believed would progress medical outcomes management.

From 1911 to 1916, Codman recorded and published 123 errors on 337 patients hospitalized in his care. The cause of errors ranged from lack of knowledge and skill to poor surgical judgment and an absense of care or equipment. He sent copies of his annual hospital reports to major U.S. hospitals challenging them to document their outcomes. But hospitals would not follow his lead. Undeterred, Codman made his reports available to the public allowing patients to be well-informed when seeking care from hospitals.

At a local medical society meeting one evening, Codman blatantly displayed a cartoon (drawn by a friend) showing an ostrich with its head in the sand kicking up sand and golden eggs, explaining that the ostrich represented surgeons and hospital administrators whose only interest was in mining financial rewards – not improved care. From this, he was asked to resign from the society. Shunned by his peers, many of whom no longer referred patients to him, his views were widely ignored by the medical profession.

Through his work, he was a founder of the American College of Surgeons that later became known as the Joint Commission on Accreditation of Healthcare Organizations.
Ahead of his time, Codman once wrote, “We believe it is the duty of every hospital to establish a follow-up system, so that as far as possible the result of every case will be available at all times for investigation by members of the staff, the trustees, or administration, or by other authorized investigators or statisticians.”

Had his peers not ignored his actions and views on improving patient outcomes, one might easily conclude that the rapid advancement of medical outcomes would be light years ahead today.

Since his death, Codman’s impact on the medical profession is viewed quite differently. In 2014, over a century following Codman’s efforts to reform the medical world, a group a physicians raised money to establish a granite and bronze memorial at Codman’s gravesite.

Doing the right thing to benefit the public takes immeasurable courage. Constructing and implementing a contrarian approach may seem disruptive – especially to your peers. These so-called disruptions may eventually reveal themselves as new areas of thought, research and ingenuity. Through his struggles, there’s no doubt that Dr. Ernest Amory Codman was a true medical pioneer.

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Autopsies – The Ultimate Medical Audit

AutopsySixty years ago, about half of all patients who died in hospitals were autopsied to determine the cause of death – which also advanced the knowledge of medicine. In fact, autopsies were considered routine. For some family members, autopsies provided a sense of closure that was desperately needed during an emotional time.

By 1971, this practice changed dramatically when a decision by The Joint Commission – a federal organization that accredits healthcare facilities – dropped the autopsy requirement rates for community hospitals and teaching facilities, which were 20 percent and 25 percent, respectively. Simply put, the practice of performing autopsies on a regular basis was no longer in vogue.

At the time, hospitals were simply performing autopsies to comply with this requirement – not to gain medical insight. Largely due to autopsy cost, which were generally paid by hospitals, medical providers pressured the commission to eliminate the requirements altogether. The commission eventually relented, as it was determined that too many hospitals were performing shoddy autopsies that revealed little additional information to advance the understanding of diseases and the effectiveness of various treatments.

Today, approximately five percent of patients who die in hospitals receive an autopsy. As many as 40 percent of hospitals don’t perform autopsies at all. Many of the autopsies that are performed – such as for the musician, Prince – are to discover any evidence of foul play or suspicious circumstances, perhaps requiring a government-assigned coroner or a medical examiner to review the case. Due to the nature of educating medical students, teaching hospitals are more likely to undertake autopsies than non-teaching facilities. But the decline in autopsies most assuredly means the death certificates are not likely to be as accurate when determining the cause of death.

At a family’s request – and their own expense – autopsies can still be performed. But due to sensitivity and cost issues (an autopsy can run $1,500 or more), most grieving families shun autopsies. Health insurance companies do not cover the cost of autopsies because it does not relate to the health or well-being of a living person.

Moving beyond the cost and sensitivity issues, autopsies do provide a great deal of value to the medical world. Studies show that doctors make diagnostic errors in about 25 percent of cases. These errors remain unknown due to the absence of autopsies, consequently resulting in incorrect information used on death certificates.

In 1998, the Journal of the American Medical Association reported that autopsy results revealed that clinicians misdiagnosed the cause of death up to 40 percent of the time. Other studies indicate that 10- to- 30 percent of autopsies performed reveal previously undiagnosed conditions, many by unreported medical errors. It would be intriguing to know whether fewer medical errors occurred in hospitals when autopsies were more prevalent. Unfortunately, we don’t have such data to definitively render such comparisons.

It stands to reason that autopsies may provide additional learning for physicians and hospitals during weekly or monthly peer review meetings, allowing for new initiatives and policies to emerge that will avert future medical errors. Such evaluations can only come from the autopsy table.

Resuscitating the slow death of the autopsy may actually be a solution to learning more about the frequency of fatal medical errors and to advance the scientific knowledge of medicine. With at least 30 percent of health costs being considered ‘wasted’ cost, why not divert a small portion of this waste to reveal truths we must eventually confront?

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Preventable Fatalities in Hospitals
Gathering the Right Statistics

Silent Death: Approximately 252,000 patients die annually in hospitals due to preventable medical mistakes.

Silent Death: Preventable medical errors in hospitals.

A recent report published in The BMJ by Dr. Martin Makary and Michael Daniel, both from Johns Hopkins University School of Medicine, generated a great deal of national exposure from the mainstream media – and for good reason. We have known for years that fatalities due to preventable mistakes made in U.S. hospitals are enormous. In fact, medical errors are the third-leading cause of death in this country, behind only heart disease and cancer. But the number of medical-error fatalities are seldom reported or collected by local and national health officials.

The report estimates that about 251,000 patients die annually in hospitals due to preventable medical mistakes. However, this is considered to be a low estimate because the authors tracked only errors documented in health records, and included only hospital patients. For many obvious reasons, mostly due to malpractice and reputation concerns, medical errors are grossly underreported.

In addition to the report, the authors published a letter directed to the U.S. Centers for Disease Control and Prevention (CDC) suggesting that death certificates have serious limitations by not listing the preventable complications that contributed to the death of patients. The authors, no doubt, agree with our ‘Silently Harmed’ white papers which state “preventable harm in hospitals appears to be an epidemic, and until it is exposed and meaningful reporting methods are embraced and enforced, we have no clear process to measure improvement.”

The United States currently uses a collection system on national health statistics that does not track medical errors. Death by diagnostic and medication errors, communication breakdowns and other system errors are not counted nor included on the death certificate. This is because U.S. health statistics are based on International Classification of Disease (ICD) codes, instituted in 1949.

Bob Anderson, chief of the CDC’s mortality statistics branch, told National Public Radio recently that such reporting would be hard to change “unless we had a really compelling reason to do so.”

This particular comment struck a raw nerve with me. I can think of at least 251K+ ‘compelling’ reasons to change how we track mortality statistics in this country!

When will we finally break away from our adherence to past practices and realize that for medical outcomes to eventually improve, we must accept and embrace new priorities that will address the third-leading cause of death in the United States? For real progress to take hold in healthcare, we must first confront the brutal facts by gathering pertinent measurable statistics to serve as concrete benchmarks for future improvement.

Now that would be compelling!

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