Wednesday, September 26, 2012

Cause of Death: Medical Error and Overtreatment - Dr. Marty Makary - WSJ

In my book, Unaccountable, I detail the transparency revolution in medicine, give consumers tools to navigate the system, and warn of the perverse incentives that flawed measuring systems produce.

Little did I know that the book and my recent article for The Wall Street Journal would ignite a national conversation about how to fix healthcare and make it safer.

The most gratifying aspect for me has been the outpouring of emails from doctors and nurses who feel a growing divide between their front-line wisdom and a new corporate hospital climate.  Transparency is their manifesto.

The many patients who have sent me their personal stories remind me that the problem has a tremendous emotional as well as financial cost.

For example, in response to my recent article for The Journal, Cynthia McLendonshared this story:

We spent Sunday night in the ER with my mother-in-law (not unusual). We have a laminated sheet that we bring with us that lists all of her doctors, her daily meds and time she takes them, her dialysis schedule, what she takes on dialysis days and non-dialysis days, location of her fistula, prior conditions, allergies and we can all recite her entire medical history. Despite all this, we still have conversations every time at the same hospital like this:
Dr. : She had a mitral valve replacement
Us: Aortic
Dr. It says mitral.
Us: We told you last time it was aortic. It was done at this hospital by Dr X 2 years ago. It's in her record. We can have him call you.
Dr: Ok. We're going to do a CT
Us: Don't use contrast dye.
Dr. Why not?
Us: She's allergic to it. It's on that sheet, we just told you, it's also in her record and we told you again a minute ago. Because 3 admissions ago you almost killed her with it and we are trying to save you a lawsuit.

And this is at a good hospital.

WSJ reader James Jones, also writing in the comments section, is concerned about the discrimination that can result from public reporting:

In L&D [labor and delivery] today, looking at the board, I thought NO private hospital in town would take care of my patients. We are an inner city academic center, and we get the most complicated cases. I'm sure our numbers would look much worse than the Super Private Hospital down the road that doesn't take Medicaid patients.

I remember one of those private physicians calling me one night to transfer a train wreck, [the patient] had been in their ICU for weeks and wasn't getting better. I was stunned. I asked her why she couldn't take care of this patient, she said "This is YOUR kind of patient."

When I lived in Nashville I remember a physician friend telling me that if I wanted my gall bladder out go to one of the private hospitals, their food was better. But If I were truly sick, to go to Vanderbilt.

None of us walk on water, but for some of us, the water is just a lot deeper and more treacherous. So a grading system has to take that into account.

As a surgeon at a large referral hospital, Dr. Jones' comments echo true to my world.

I, too, take care of sicker, more high-risk patients, which is why we need to use doctor-endorsed ways of measuring quality.  Flawed rating systems that do not take this difference into account run the risk of steering patients the wrong way and punishing doctors like Dr. Jones for doing admirable work.

Doctors' groups measuring quality, like the American College of Surgeons, have developed mathematical ways to appropriately adjust for differences in patient risk seen at one hospital versus another.

In addition, patient satisfaction survey questions asking: "Was your plan of care explained to your satisfaction?" also measure universal best practices. While there is no single best way to measure healthcare, there are many databases managed by doctors associations that measure hospital outcomes. The question we must now ask as a society is: Do patients have a right to know about the quality of their hospitals?

Transparency has the potential to change the focus of a marketplace.  Currently, we have competition in healthcare, but the competition is at the wrong level.  With increased transparency of performance and the realities of patient experience, hospitals will respond by allocating resources into quality and an improved experience.

As a medical student, I never heard of the problem of medical error or overtreatment discussed, let alone quantified.  Later, the Institute of Medicine reported the estimate that those problems result in up to 98,000 deaths each year.  Proud of my profession, I, along with my peers, disputed the figure.

But study after study by respected institutions have shown that the highly-cited 98,000 deaths figure vastly understated the problem.

More recent, more valid studies put the figure far higher.

The latest Institute of Medicine report cites a leading study that quantifies the problem at nearly double the prior estimate (180,00 deaths) among Medicare beneficiaries alone, which would rank preventable harm as the number 3 cause of death in the U.S. after cardiovascular disease and cancer.

We as a nation spend a lot of money on heart disease and cancer, but with preventable deaths, we are still debating if we even have a problem?

The problem of over-treatment and under-treatment also gets bigger the more we study it.

Physician specialists have been reporting in their own peer-reviewed literature and in our top journals that individual services (stents, PAP smears, follow-up radiology tests, certain prescribed medications, etc.) are not indicated up to 40% of the time.

We need to step back and take a global look at these studies in aggregate and put them in the context of what front-line doctors are telling us about the vitals signs of our healthcare system.

If we are going to finally get serious about addressing the large burden of waste in healthcare so that American businesses can thrive and healthcare can accommodate our projected aging population, the first step is to be open and honest about the task.