More Treatment, More Mistakes - NYTimes.com:
July 31, 2012
Dr. Sanjay Gupta
"According to a 1999 report by the Institute of Medicine, as many as 98,000 Americans were dying every year because of medical mistakes...
But a reasonable estimate is that medical mistakes now kill around 200,000 Americans every year. That would make them one of the leading causes of death in the United States. Why have these mistakes been so hard to prevent?
Here’s one theory. It is a given that American doctors perform a staggering number of tests and procedures, far more than in other industrialized nations, and far more than we used to. Since 1996, the percentage of doctor visits leading to at least five drugs’ being prescribed has nearly tripled, and the number of M.R.I. scans quadrupled.
Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not. In a recent anonymous survey, orthopedic surgeons said 24 percent of the tests they ordered were medically unnecessary. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.
Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error. CT and M.R.I. scans can lead to false positives and unnecessary operations, which carry the risk of complications like infections and bleeding. The more medications patients are prescribed, the more likely they are to accidentally overdose or suffer an allergic reaction....
So what do we do to be safer? Many smart people have tackled this question. Peter Pronovost at Johns Hopkins developed a checklist shown to bring hospital-acquired infections down to close to zero. There are rules against disturbing nurses while they dispense medications and software that warns doctors when patients’ prescriptions will interact badly. There are policies designed to empower nurses to confront doctors if they see something wrong, even if a senior doctor is at fault.
What may be even more important is remembering the limits of our power. More — more procedures, more testing, more treatment — is not always better. In 1979, Stephen Bergman, under the pen name Dr. Samuel Shem, published rules for hospitals in his caustically humorous novel, “The House of God.” Rule No. 13 reads: “The delivery of medical care is to do as much nothing as possible.” First, do no harm.
One place where I have seen these issues addressed is in Morbidity and Mortality, or M and M — a weekly gathering of doctors, off limits to the public, which serves in most hospitals as a forum for the discussion of mistakes, complications, deaths and unusual cases. It is a sort of quality-assurance conference where doctors hold one another accountable and learn from one another’s mistakes. They are some of the most candid and indelible meetings I have ever attended....
At my first M and M as a medical student, I heard the story of a patient who had received antibiotics for an upper respiratory tract infection. Two weeks later she developed joint pain and blisters on her chest and arms, a condition known as Stevens-Johnson syndrome, which can be caused by an allergic reaction to antibiotics. She ended up with sepsis, a bodywide infection, and spent two weeks in intensive care. She, too, survived, but most stunning was the doctor’s admission that her original ailment had been a mild viral illness — she hadn’t even needed the antibiotics that led to such a terrible reaction. Years later, that case still makes me think harder about every test I order and every medication I prescribe...."
Sanjay Gupta, the associate chief of neurosurgery at Grady Memorial Hospital and the chief medical correspondent for CNN, is the author of the novel “Monday Mornings.”
Showing posts with label hospitals. Show all posts
Showing posts with label hospitals. Show all posts
Tuesday, July 31, 2012
Monday, August 29, 2011
New research shows how some common tests and procedures aren’t just expensive, but can do more harm than good
One Word Can Save Your Life: No!
New research shows how some common tests and procedures aren’t just expensive, but can do more harm than good.
A growing body of evidence shows that some common tests and procedures are overused and often don't help patients. Another resource is uspreventiveservicestaskforce.org, which offer recommendations based on reviews of research by an independent panel of medical experts and physicians.
by Sharon Begley | Newsweek | August 14, 2011 10:0 AM EDT
Dr. Stephen Smith, Professor emeritus of family medicine at Brown University School of Medicine, tells his physician not to order a PSA blood test for prostate cancer or an annual electrocardiogram to screen for heart irregularities, since neither test has been shown to save lives. Rather, both tests frequently find innocuous quirks that can lead to a dangerous odyssey of tests and procedures. Dr. Rita Redberg, professor of medicine at the University of California, San Francisco, and editor of the prestigious Archives of Internal Medicine, has no intention of having a screening mammogram even though her 50th birthday has come and gone. That’s the age at which women are advised to get one. But, says Redberg, they detect too many false positives (suspicious spots that turn out, upon biopsy, to be nothing) and tumors that might regress on their own, and there is little if any evidence that they save lives.
These physicians are not anti-medicine. They are not trying to save money on their copayments or deductibles. And they are not trying to rein in the nation’s soaring health-care costs, which at $2.7 trillion account for fully one sixth of every dollar spent in the U.S. They are applying to their personal lives a message they have become increasingly vocal about in their roles as biomedical researchers and doctors: more health care often means worse health. “There are many areas of medicine where not testing, not imaging, and not treating actually result in better health outcomes,” Redberg says. In other words, “less is more.” Archives, which is owned by the American Medical Association, has been publishing study after study about tests and treatments that do more harm than good.
That less health care can lead to better health and, conversely, that more health care can harm health, runs counter to most patients’ conviction that screenings and treatments are inherently beneficial. That belief is fueled by the flood of new technologies and drugs that have reached the market in the past two or three decades, promising to prevent disease and extend life. Most of us wouldn’t think twice if our doctor offered a test that has the power to expose a lurking tumor, or a clogged artery, or a heart arrhythmia. Better to know—and get treated—than to take any risks, the reasoning goes.
In fact, for many otherwise healthy people, tests often lead to more tests, which can lead to interventions based on a possible problem that may have gone away on its own or ultimately proved harmless. Patients can easily be fooled when a screening test detects, or an intervention treats, an abnormality, and their health improves, says cardiologist Michael Lauer of the National Heart, Lung, and Blood Institute. In fact, says Lauer, that abnormality may not have been the cause of the problem or a threat to future health: “All you’ve done is misclassify someone with no disease as having disease.”
From PSA tests for prostate cancer (which more than 20 million U.S. men undergo every year) to surgery for chronic back pain to simple antiobiotics for sinus infection, a remarkable number and variety of tests and treatments are now proving either harmful or only as helpful as a placebo.
This realization comes at a time when Medicare has emerged as a fat target in the debate over taming the deficit, with politicians proposing to slash costs by raising the age of eligibility or even eliminating the program. Experts estimate that the U.S. spends hundreds of billions of dollars every year on medical procedures that provide no benefit or a substantial risk of harm, suggesting that Medicare could save both money and lives if it stopped paying for some common treatments. “There’s a reason we spend almost twice as much per capita on health care [as other developed countries] with no gain in health or longevity,” argues Dr. Steven Nissen, the noted cardiologist at the Cleveland Clinic. “We spend money like a drunken sailor on shore leave.”
Many medical advances, of course, have saved lives and eased suffering for millions of people. Screening tests like mammograms can lead to early treatment of breast cancer, especially for women with hereditary risk or a strong family history of the disease. For cancer patients who report back pain, MRIs can prove invaluable for spotting tumors that have metastasized to the bones, allowing doctors to intervene before it’s too late. The years between 1980 and 2004 saw a 50 percent decline in the death rate from coronary heart disease thanks to better treatments and drugs that reduce cholesterol and blood pressure. At least 7,300 lives are saved every year thanks to colonoscopies.
The dilemma, say a growing number of physicians and expert medical panels, is that some of this same health care that helps certain patients can, when offered to everyone else, be useless or even detrimental. Some of the most disturbing examples involve cardiology. At least five large, randomized controlled studies have analyzed treatments for stable heart patients who have nothing worse than mild chest pain. The studies compared invasive procedures including angioplasty, in which a surgeon mechanically widens a blocked blood vessel by crushing the fatty deposits called plaques; stenting, or propping open a vessel with wire mesh; and bypass surgery, grafting a new blood vessel onto a blocked one. Every study found that the surgical procedures didn’t improve survival rates or quality of life more than noninvasive treatments including drugs (beta blockers, cholesterol-lowering statins, and aspirin), exercise, and a healthy diet. They were, however, far more expensive: stenting costs Medicare more than $1.6 billion a year.
If that finding makes you scratch your head—how can propping open a narrowed blood vessel not be wonderfully effective?—you’re not alone. Many cardiologists had the same reaction when these studies were published. It turns out that the big blockages that show up on CT scans and other imaging, and that were long assumed to cause heart attacks, usually don’t—but treating them can. That’s because when you disrupt these blockages through surgery, you “spray a whole lot of debris down into the tiny blood vessels, which can trigger a heart attack or stroke,” says Nortin Hadler, a professor of medicine at the University of North Carolina, whose book on overtreatment in the elderly, Rethinking Aging, will be published next month. Many of the 500,000 elective angioplasties (at least $50,000 each) performed every year are done on patients who could benefit more from drugs, exercise, and healthy eating.
New technology has sometimes made the problem more acute. Where once arterial blockages were detected by chest X-ray, now doctors can use cardiac CT angiography, which shows the heart and coronary arteries in dramatic 3-D. When it was introduced a decade ago to screen for cardiovascular disease, it seemed almost miraculous: a 2005 cover of Time trumpeted that it could “stop a heart attack before it happens.” Difficult as it is to believe, however, there can be such a thing as too much information, especially from new imaging technology. “Our imaging and diagnostic tests are so good, we can see things we couldn’t see before,” says Lauer of the National Heart, Lung, and Blood Institute. “But our ability to understand what we’re seeing and to know if we should intervene hasn’t kept up.”
In a recent study, John McEvoy, a heart specialist at Johns Hopkins Medical Institutions, and colleagues found that 1,000 low-risk patients who had CT angiography had no fewer heart attacks or deaths over the next 18 months than 1,000 patients who did not undergo the screening. But they did have more drugs, tests, and invasive procedures such as stenting, all of which carry a risk of side effects, surgical complications, and even death. The CT itself has a potential side effect: by exposing patients to high levels of radiation, it raises the risk of cancer. “Low-risk patients without symptoms don’t benefit from CT angiography,” says McEvoy, though high-risk patients with heart disease might.
The Cleveland Clinic’s Nissen has seen firsthand what happens when doctors, armed with too much information, perform what turn out to be unnecessary procedures. In 2009 a 52-year-old woman with chest pain underwent a cardiac CT at a community hospital. Neither her LDL (bad) cholesterol nor her C-reactive protein (another risk factor for heart disease) were elevated. But since the CT showed several coronary plaques, her physicians performed coronary angiography. Complications ensued, and the woman wound up undergoing more procedures, one of which tore an artery. She eventually went to the Cleveland Clinic for a heart transplant—not because she had heart disease when it all started, says Nissen, but because of the cascading interventions triggered by the CT.
Nissen regularly counsels asymptomatic, low-risk patients against having cardiac CT, echocardiograms, and even treadmill stress tests; studies show they produce many false positives, leading to risky interventions. Even a clean scan can lead to worse health, if it makes people believe they can eat whatever they want and stop exercising. “I’ve had colleagues gain weight after a negative heart scan,” apparently figuring they were home free, says UCSF’s Redberg.
Radiologists and other physicians who diagnose or treat back pain have their own version of the CT: it’s called magnetic resonance imaging, or MRI. Just as cardiac CT makes sense in principle, so does getting a high-resolution image of the spine if someone is suffering lower back pain with no clear cause. An MRI typically costs about $3,000 and is designed to spot everything from bulging discs to hairline fractures. Find any of those things, the logic goes, and you can treat the problem surgically. But there’s a fundamental flaw: clinical trials have shown that back surgery, including vertebroplasty (putting special cement on a tiny spinal fracture) and spinal fusion, is no more effective at alleviating ordinary pain than plain-old rest and mild exercise. But like any surgery, it carries risks. Last year the American College of Physicians warned that “routine imaging [for low back pain] is not associated with clinically meaningful benefits but can lead to harms.” That’s because the “abnormalities” seen in an MRI often have nothing to do with the back pain (people without pain have them, too), but seeing something on a scan makes a physician feel compelled to get rid of it. “There is a longstanding fallacy among physicians that if you find something different from what you perceive to be ‘normal,’ then it must be the cause of the patient’s problem,” says UNC’s Hadler.
Dr. James Goodwin, a geriatrician at the University of Texas Medical Branch, cites an extreme example of this fallacy in the case of a frail 84-year-old woman who was told by her gastroenterologist that it was time for another colonoscopy, just a few years after her last one showed no problems. She died when the procedure perforated her colon. Though this outcome is rare, the recommendation that led to the woman’s death is all too common, says Goodwin, even though expert groups advise against screening colonscopies for anyone over 75 or who has had a normal result within the past 10 years. He says he was dumbfounded when his elderly patients kept receiving “reminders” from their gastroenterologists telling them it was time for another colonoscopy—seven or five or even two years after their last normal one.
Both curious and concerned, Goodwin launched a study of Medicare patients. Fully 46 percent had a screening colonoscopy fewer than seven years after a negative one. Making matters worse, many of them were over 80.
Medical practice also suffers from a kind of mission creep: if a treatment works in severe disease, some doctors assume it will work in milder disease. But that is not necessarily so. Antidepressants, for instance, have been shown in randomized trials to help with severe depression but not with moderate or mild depression, yet are widely prescribed for those conditions. Drugs called proton pump inhibitors (PPIs) are effective against gastric reflux and rare esophageal diseases as well as some ulcers, but at least half, and possibly 70 percent, of the 113 million U.S. prescriptions for PPIs each year are for conditions they don’t help, such as run-of-the-mill stomachaches. PPIs can cause bone fractures, severe and hard-to-treat bacterial infections, and pneumonia. Millions of people are being put at risk unnecessarily, which is one reason treating adverse drug reactions costs the U.S. $200 billion a year.
Statins, common cholesterol-reducing drugs, may also not benefit some people who are taking them. Statins are proved to help people with both heart disease and high cholesterol, but not those with just high cholesterol. The drugs are nevertheless widely prescribed to patients who fit the latter description, despite adverse effects, such as severe muscle disease in up to 20 percent of patients. Similarly, cardiac resynchronization therapy, a special pacemaker that causes the right and left ventricles to beat in sync, can save the life of a patient with congestive heart failure whose ventricles are at least 150 milliseconds out of sync. Yet patients with a mistiming of 120-150 milliseconds are receiving the devices.
Low-tech tests should sometimes be avoided, too. In an Archives paper published this month, a panel of physicians, led by Brown’s Smith, announced its first list of tests and treatments that should be dropped altogether for certain patients and ailments: antibiotics for sinus infections, imaging for low back pain, osteoporosis screening for women under 65, and electrocardiograms and other cardiac screening in low-risk patients. Even blood panels for healthy adults made the list. Today’s comprehensive blood tests measure 15 or so enzymes, proteins, lipids, and the like. Yet by chance alone, if you test for 20 things, something will fall outside the bounds of “normal,” often due to simple lab error.
Many doctors don’t seem to be getting the message about useless and harmful health care. Medicare pays them more than $100 million a year for screening colonoscopies; some 40 percent are for people in whom they will almost certainly harm more than help. Arthroscopic knee surgery for osteoarthritis is performed about 650,000 times a year; studies show that it, too, is no more effective than placebo treatment, yet taxpayers and private insurers pay for it. And although several large studies, including the Occluded Artery Trial in 2006, have shown that inserting a stent to prop open a blocked artery more than 24 hours after a heart attack does not improve survival rates or reduce the risk of another coronary compared with drugs alone, the practice continues at a rate of 100,000 such procedures a year, estimate researchers led by Dr. Judith Hochman, a cardiologist at New York University. “We’re killing more people than we’re saving with these procedures,” says UT’s Goodwin. “It’s as simple as that.”
August 14, 2011 10:0am
New research shows how some common tests and procedures aren’t just expensive, but can do more harm than good.
A growing body of evidence shows that some common tests and procedures are overused and often don't help patients. Another resource is uspreventiveservicestaskforce.org, which offer recommendations based on reviews of research by an independent panel of medical experts and physicians.
by Sharon Begley | Newsweek | August 14, 2011 10:0 AM EDT
Dr. Stephen Smith, Professor emeritus of family medicine at Brown University School of Medicine, tells his physician not to order a PSA blood test for prostate cancer or an annual electrocardiogram to screen for heart irregularities, since neither test has been shown to save lives. Rather, both tests frequently find innocuous quirks that can lead to a dangerous odyssey of tests and procedures. Dr. Rita Redberg, professor of medicine at the University of California, San Francisco, and editor of the prestigious Archives of Internal Medicine, has no intention of having a screening mammogram even though her 50th birthday has come and gone. That’s the age at which women are advised to get one. But, says Redberg, they detect too many false positives (suspicious spots that turn out, upon biopsy, to be nothing) and tumors that might regress on their own, and there is little if any evidence that they save lives.
These physicians are not anti-medicine. They are not trying to save money on their copayments or deductibles. And they are not trying to rein in the nation’s soaring health-care costs, which at $2.7 trillion account for fully one sixth of every dollar spent in the U.S. They are applying to their personal lives a message they have become increasingly vocal about in their roles as biomedical researchers and doctors: more health care often means worse health. “There are many areas of medicine where not testing, not imaging, and not treating actually result in better health outcomes,” Redberg says. In other words, “less is more.” Archives, which is owned by the American Medical Association, has been publishing study after study about tests and treatments that do more harm than good.
That less health care can lead to better health and, conversely, that more health care can harm health, runs counter to most patients’ conviction that screenings and treatments are inherently beneficial. That belief is fueled by the flood of new technologies and drugs that have reached the market in the past two or three decades, promising to prevent disease and extend life. Most of us wouldn’t think twice if our doctor offered a test that has the power to expose a lurking tumor, or a clogged artery, or a heart arrhythmia. Better to know—and get treated—than to take any risks, the reasoning goes.
In fact, for many otherwise healthy people, tests often lead to more tests, which can lead to interventions based on a possible problem that may have gone away on its own or ultimately proved harmless. Patients can easily be fooled when a screening test detects, or an intervention treats, an abnormality, and their health improves, says cardiologist Michael Lauer of the National Heart, Lung, and Blood Institute. In fact, says Lauer, that abnormality may not have been the cause of the problem or a threat to future health: “All you’ve done is misclassify someone with no disease as having disease.”
From PSA tests for prostate cancer (which more than 20 million U.S. men undergo every year) to surgery for chronic back pain to simple antiobiotics for sinus infection, a remarkable number and variety of tests and treatments are now proving either harmful or only as helpful as a placebo.
This realization comes at a time when Medicare has emerged as a fat target in the debate over taming the deficit, with politicians proposing to slash costs by raising the age of eligibility or even eliminating the program. Experts estimate that the U.S. spends hundreds of billions of dollars every year on medical procedures that provide no benefit or a substantial risk of harm, suggesting that Medicare could save both money and lives if it stopped paying for some common treatments. “There’s a reason we spend almost twice as much per capita on health care [as other developed countries] with no gain in health or longevity,” argues Dr. Steven Nissen, the noted cardiologist at the Cleveland Clinic. “We spend money like a drunken sailor on shore leave.”
Many medical advances, of course, have saved lives and eased suffering for millions of people. Screening tests like mammograms can lead to early treatment of breast cancer, especially for women with hereditary risk or a strong family history of the disease. For cancer patients who report back pain, MRIs can prove invaluable for spotting tumors that have metastasized to the bones, allowing doctors to intervene before it’s too late. The years between 1980 and 2004 saw a 50 percent decline in the death rate from coronary heart disease thanks to better treatments and drugs that reduce cholesterol and blood pressure. At least 7,300 lives are saved every year thanks to colonoscopies.
The dilemma, say a growing number of physicians and expert medical panels, is that some of this same health care that helps certain patients can, when offered to everyone else, be useless or even detrimental. Some of the most disturbing examples involve cardiology. At least five large, randomized controlled studies have analyzed treatments for stable heart patients who have nothing worse than mild chest pain. The studies compared invasive procedures including angioplasty, in which a surgeon mechanically widens a blocked blood vessel by crushing the fatty deposits called plaques; stenting, or propping open a vessel with wire mesh; and bypass surgery, grafting a new blood vessel onto a blocked one. Every study found that the surgical procedures didn’t improve survival rates or quality of life more than noninvasive treatments including drugs (beta blockers, cholesterol-lowering statins, and aspirin), exercise, and a healthy diet. They were, however, far more expensive: stenting costs Medicare more than $1.6 billion a year.
If that finding makes you scratch your head—how can propping open a narrowed blood vessel not be wonderfully effective?—you’re not alone. Many cardiologists had the same reaction when these studies were published. It turns out that the big blockages that show up on CT scans and other imaging, and that were long assumed to cause heart attacks, usually don’t—but treating them can. That’s because when you disrupt these blockages through surgery, you “spray a whole lot of debris down into the tiny blood vessels, which can trigger a heart attack or stroke,” says Nortin Hadler, a professor of medicine at the University of North Carolina, whose book on overtreatment in the elderly, Rethinking Aging, will be published next month. Many of the 500,000 elective angioplasties (at least $50,000 each) performed every year are done on patients who could benefit more from drugs, exercise, and healthy eating.
New technology has sometimes made the problem more acute. Where once arterial blockages were detected by chest X-ray, now doctors can use cardiac CT angiography, which shows the heart and coronary arteries in dramatic 3-D. When it was introduced a decade ago to screen for cardiovascular disease, it seemed almost miraculous: a 2005 cover of Time trumpeted that it could “stop a heart attack before it happens.” Difficult as it is to believe, however, there can be such a thing as too much information, especially from new imaging technology. “Our imaging and diagnostic tests are so good, we can see things we couldn’t see before,” says Lauer of the National Heart, Lung, and Blood Institute. “But our ability to understand what we’re seeing and to know if we should intervene hasn’t kept up.”
In a recent study, John McEvoy, a heart specialist at Johns Hopkins Medical Institutions, and colleagues found that 1,000 low-risk patients who had CT angiography had no fewer heart attacks or deaths over the next 18 months than 1,000 patients who did not undergo the screening. But they did have more drugs, tests, and invasive procedures such as stenting, all of which carry a risk of side effects, surgical complications, and even death. The CT itself has a potential side effect: by exposing patients to high levels of radiation, it raises the risk of cancer. “Low-risk patients without symptoms don’t benefit from CT angiography,” says McEvoy, though high-risk patients with heart disease might.
The Cleveland Clinic’s Nissen has seen firsthand what happens when doctors, armed with too much information, perform what turn out to be unnecessary procedures. In 2009 a 52-year-old woman with chest pain underwent a cardiac CT at a community hospital. Neither her LDL (bad) cholesterol nor her C-reactive protein (another risk factor for heart disease) were elevated. But since the CT showed several coronary plaques, her physicians performed coronary angiography. Complications ensued, and the woman wound up undergoing more procedures, one of which tore an artery. She eventually went to the Cleveland Clinic for a heart transplant—not because she had heart disease when it all started, says Nissen, but because of the cascading interventions triggered by the CT.
Nissen regularly counsels asymptomatic, low-risk patients against having cardiac CT, echocardiograms, and even treadmill stress tests; studies show they produce many false positives, leading to risky interventions. Even a clean scan can lead to worse health, if it makes people believe they can eat whatever they want and stop exercising. “I’ve had colleagues gain weight after a negative heart scan,” apparently figuring they were home free, says UCSF’s Redberg.
Radiologists and other physicians who diagnose or treat back pain have their own version of the CT: it’s called magnetic resonance imaging, or MRI. Just as cardiac CT makes sense in principle, so does getting a high-resolution image of the spine if someone is suffering lower back pain with no clear cause. An MRI typically costs about $3,000 and is designed to spot everything from bulging discs to hairline fractures. Find any of those things, the logic goes, and you can treat the problem surgically. But there’s a fundamental flaw: clinical trials have shown that back surgery, including vertebroplasty (putting special cement on a tiny spinal fracture) and spinal fusion, is no more effective at alleviating ordinary pain than plain-old rest and mild exercise. But like any surgery, it carries risks. Last year the American College of Physicians warned that “routine imaging [for low back pain] is not associated with clinically meaningful benefits but can lead to harms.” That’s because the “abnormalities” seen in an MRI often have nothing to do with the back pain (people without pain have them, too), but seeing something on a scan makes a physician feel compelled to get rid of it. “There is a longstanding fallacy among physicians that if you find something different from what you perceive to be ‘normal,’ then it must be the cause of the patient’s problem,” says UNC’s Hadler.
Dr. James Goodwin, a geriatrician at the University of Texas Medical Branch, cites an extreme example of this fallacy in the case of a frail 84-year-old woman who was told by her gastroenterologist that it was time for another colonoscopy, just a few years after her last one showed no problems. She died when the procedure perforated her colon. Though this outcome is rare, the recommendation that led to the woman’s death is all too common, says Goodwin, even though expert groups advise against screening colonscopies for anyone over 75 or who has had a normal result within the past 10 years. He says he was dumbfounded when his elderly patients kept receiving “reminders” from their gastroenterologists telling them it was time for another colonoscopy—seven or five or even two years after their last normal one.
Both curious and concerned, Goodwin launched a study of Medicare patients. Fully 46 percent had a screening colonoscopy fewer than seven years after a negative one. Making matters worse, many of them were over 80.
Medical practice also suffers from a kind of mission creep: if a treatment works in severe disease, some doctors assume it will work in milder disease. But that is not necessarily so. Antidepressants, for instance, have been shown in randomized trials to help with severe depression but not with moderate or mild depression, yet are widely prescribed for those conditions. Drugs called proton pump inhibitors (PPIs) are effective against gastric reflux and rare esophageal diseases as well as some ulcers, but at least half, and possibly 70 percent, of the 113 million U.S. prescriptions for PPIs each year are for conditions they don’t help, such as run-of-the-mill stomachaches. PPIs can cause bone fractures, severe and hard-to-treat bacterial infections, and pneumonia. Millions of people are being put at risk unnecessarily, which is one reason treating adverse drug reactions costs the U.S. $200 billion a year.
Statins, common cholesterol-reducing drugs, may also not benefit some people who are taking them. Statins are proved to help people with both heart disease and high cholesterol, but not those with just high cholesterol. The drugs are nevertheless widely prescribed to patients who fit the latter description, despite adverse effects, such as severe muscle disease in up to 20 percent of patients. Similarly, cardiac resynchronization therapy, a special pacemaker that causes the right and left ventricles to beat in sync, can save the life of a patient with congestive heart failure whose ventricles are at least 150 milliseconds out of sync. Yet patients with a mistiming of 120-150 milliseconds are receiving the devices.
Low-tech tests should sometimes be avoided, too. In an Archives paper published this month, a panel of physicians, led by Brown’s Smith, announced its first list of tests and treatments that should be dropped altogether for certain patients and ailments: antibiotics for sinus infections, imaging for low back pain, osteoporosis screening for women under 65, and electrocardiograms and other cardiac screening in low-risk patients. Even blood panels for healthy adults made the list. Today’s comprehensive blood tests measure 15 or so enzymes, proteins, lipids, and the like. Yet by chance alone, if you test for 20 things, something will fall outside the bounds of “normal,” often due to simple lab error.
Many doctors don’t seem to be getting the message about useless and harmful health care. Medicare pays them more than $100 million a year for screening colonoscopies; some 40 percent are for people in whom they will almost certainly harm more than help. Arthroscopic knee surgery for osteoarthritis is performed about 650,000 times a year; studies show that it, too, is no more effective than placebo treatment, yet taxpayers and private insurers pay for it. And although several large studies, including the Occluded Artery Trial in 2006, have shown that inserting a stent to prop open a blocked artery more than 24 hours after a heart attack does not improve survival rates or reduce the risk of another coronary compared with drugs alone, the practice continues at a rate of 100,000 such procedures a year, estimate researchers led by Dr. Judith Hochman, a cardiologist at New York University. “We’re killing more people than we’re saving with these procedures,” says UT’s Goodwin. “It’s as simple as that.”
August 14, 2011 10:0am
Wednesday, April 13, 2011
Giving Doctors Orders
Giving Doctors Orders
NYT
By MAUREEN DOWD
April 12, 2011
When my brother went into the hospital with pneumonia, he quickly contracted four other infections in the intensive care unit.
Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.
“It could be anything,” he said. “It could be my tie spreading germs.”
I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.
Michael died in that I.C.U. A couple years later, I read reports about how neckties and lab coats worn by doctors and clinical workers were suspected as carriers of deadly germs. Infections kill 100,000 patients in hospitals and other clinics in the U.S. every year.
A 2004 study of New York City doctors and clinicians discovered that their ties were contagious with at least one type of infectious microbe. Four years ago, the British National health system initiated a “bare below the elbow” dress code barring ties, lab coats, jewelry on the hands and wrists, and long fingernails.
The Centers for Disease Control and Prevention says that health care workers, even doctors and nurses, have a “poor” record of obeying hand-washing rules.
A report in the April issue of Health Affairs indicated that one out of every three people suffer a mistake during a hospital stay.
I saw infractions of the rules in the I.C.U. where Michael died, but I never called out anyone. I was too busy trying to ingratiate myself with the doctors, nurses and orderlies, irrationally hoping that they’d treat my brother better if they liked us.
Commenting on the new report on hospital errors, CNN’s senior medical correspondent, Elizabeth Cohen, instructed viewers to “ask doctors and nurses to wash their hands” if they haven’t.
“They sometimes will actually give you a hard time, believe it or not,” she said, “and they say, ‘My gloves are on. I’m clean.’ ‘Well, I didn’t see you put those gloves on. What if you put those on with dirty hands?’ ”
I called Cohen, the author of “The Empowered Patient,” to ask her the best way to confront those taking care of you or family members. She said that you have to get over the “waiter spitting in your soup scenario,” that the medical professionals will somehow avenge themselves, by giving less attention, if you insult them.
“There are all sorts of reasons we default to being quiet,” she said. “It is general etiquette not to correct another adult, especially when this is their profession. But when the consequences are so grave, you have to summon up your courage.” You could say that you are a germaphobe, she suggested, and ask if they could please just indulge you?...?
NYT
By MAUREEN DOWD
April 12, 2011
When my brother went into the hospital with pneumonia, he quickly contracted four other infections in the intensive care unit.
Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.
“It could be anything,” he said. “It could be my tie spreading germs.”
I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.
Michael died in that I.C.U. A couple years later, I read reports about how neckties and lab coats worn by doctors and clinical workers were suspected as carriers of deadly germs. Infections kill 100,000 patients in hospitals and other clinics in the U.S. every year.
A 2004 study of New York City doctors and clinicians discovered that their ties were contagious with at least one type of infectious microbe. Four years ago, the British National health system initiated a “bare below the elbow” dress code barring ties, lab coats, jewelry on the hands and wrists, and long fingernails.
The Centers for Disease Control and Prevention says that health care workers, even doctors and nurses, have a “poor” record of obeying hand-washing rules.
A report in the April issue of Health Affairs indicated that one out of every three people suffer a mistake during a hospital stay.
I saw infractions of the rules in the I.C.U. where Michael died, but I never called out anyone. I was too busy trying to ingratiate myself with the doctors, nurses and orderlies, irrationally hoping that they’d treat my brother better if they liked us.
Commenting on the new report on hospital errors, CNN’s senior medical correspondent, Elizabeth Cohen, instructed viewers to “ask doctors and nurses to wash their hands” if they haven’t.
“They sometimes will actually give you a hard time, believe it or not,” she said, “and they say, ‘My gloves are on. I’m clean.’ ‘Well, I didn’t see you put those gloves on. What if you put those on with dirty hands?’ ”
I called Cohen, the author of “The Empowered Patient,” to ask her the best way to confront those taking care of you or family members. She said that you have to get over the “waiter spitting in your soup scenario,” that the medical professionals will somehow avenge themselves, by giving less attention, if you insult them.
“There are all sorts of reasons we default to being quiet,” she said. “It is general etiquette not to correct another adult, especially when this is their profession. But when the consequences are so grave, you have to summon up your courage.” You could say that you are a germaphobe, she suggested, and ask if they could please just indulge you?...?
Wednesday, November 24, 2010
Study Finds No Progress in Safety at Hospitals
Study Finds No Progress in Safety at Hospitals | NYT
By DENISE GRADY
Published: November 24, 2010
"Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.
The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections....
It is one of the most rigorous efforts to collect data about patient safety since a landmark report in 1999 found that medical mistakes caused as many as 98,000 deaths and more than one million injuries a year in the United States. That report, by the Institute of Medicine, an independent group that advises the government on health matters, led to a national movement to reduce errors and make hospital stays less hazardous to patients’ health....
But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found....
A recent government report found similar results, saying that in October 2008, 13.5 percent of Medicare beneficiaries — 134,000 patients — experienced “adverse events” during hospital stays. The report said the extra treatment required as a result of the injuries could cost Medicare several billion dollars a year. And in 1.5 percent of the patients — 15,000 in the month studied — medical mistakes contributed to their deaths. That report, issued this month by the inspector general of the Department of Health and Human Services, was based on a sample of Medicare records from patients discharged from hospitals...."
By DENISE GRADY
Published: November 24, 2010
"Efforts to make hospitals safer for patients are falling short, researchers report in the first large study in a decade to analyze harm from medical care and to track it over time.
The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. The most common problems were complications from procedures or drugs and hospital-acquired infections....
It is one of the most rigorous efforts to collect data about patient safety since a landmark report in 1999 found that medical mistakes caused as many as 98,000 deaths and more than one million injuries a year in the United States. That report, by the Institute of Medicine, an independent group that advises the government on health matters, led to a national movement to reduce errors and make hospital stays less hazardous to patients’ health....
But instead of improvements, the researchers found a high rate of problems. About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few — 2.4 percent — caused or contributed to a patient’s death, the study found....
A recent government report found similar results, saying that in October 2008, 13.5 percent of Medicare beneficiaries — 134,000 patients — experienced “adverse events” during hospital stays. The report said the extra treatment required as a result of the injuries could cost Medicare several billion dollars a year. And in 1.5 percent of the patients — 15,000 in the month studied — medical mistakes contributed to their deaths. That report, issued this month by the inspector general of the Department of Health and Human Services, was based on a sample of Medicare records from patients discharged from hospitals...."
Wednesday, March 04, 2009
Asking Tough Questions of Doctors
Asking Tough Questions of Doctors - WSJ.com:
""The culture around medicine is changing very quickly as patients begin to understand the full impact of medical errors and see that quality health care is not a given," says Bruce Siegel, a professor in the department of health policy at George Washington University who runs the Aligning Forces for Quality program. Many physicians are trained "to think of ourselves as little gods" and resist patients who question their authority, Dr. Siegel says. But "the more enlightened physicians are beginning to realize this could be a positive thing for health care."
""The culture around medicine is changing very quickly as patients begin to understand the full impact of medical errors and see that quality health care is not a given," says Bruce Siegel, a professor in the department of health policy at George Washington University who runs the Aligning Forces for Quality program. Many physicians are trained "to think of ourselves as little gods" and resist patients who question their authority, Dr. Siegel says. But "the more enlightened physicians are beginning to realize this could be a positive thing for health care."
The Pennsylvania Patient Safety Authority, which tracks medical errors and recommends preventive measures, says research conducted in the state shows patients are increasingly willing to ask certain questions of their doctor. It says patients will seek a better explanation of something they don't understand or question the reason for a procedure or unfamiliar drug.
But patients are most reluctant to ask anything that might be viewed as confrontational, such as requesting that health-care providers confirm a patient's identity before a procedure or asking practitioners to wash their hands, the group says. Hand washing is considered the most important preventive measure against the spread of potentially deadly infections....
Many hospitals make use of the 'Speak Up' campaign launched in 2002 by the Joint Commission, the nonprofit group that accredits hospitals. The program provides free brochures and posters to hospitals urging patients to take a role in preventing medication errors, infections and wrong-patient procedures. The brochures, available at www.jointcommission.org, provide lists of questions to ask medical practitioners, urging patients, for instance, to make sure doctors and nurses check their wristband and ask their name before administering medicine."Sunday, December 16, 2007
Myth: Hospitals Keep You Safe from Germs
Myth: Hospitals Keep You Safe from Germs
Hospital Infections Kill Tens of Thousands Every Year
ABC News
Oct. 14, 2005
There's a deadly threat hiding inside America's hospitals. What's even scarier, your hospital is probably keeping it a secret.
Maureen Daly's mother was a healthy 63-year-old woman when she had surgery to fix a broken shoulder. However, after being admitted to the hospital, Daly's mother got an infection that left her immobilized on a respirator. Daly was told that life-threatening germs are an inevitable fact of hospital life.
Daly was shocked. "I cannot accept that it would be a fact of life that you can walk into a hospital with a broken shoulder and leave practically dead," she said.
Her mother died four months later.
Betsy McCaughey, former lieutenant governor of New York and founder of the Committee to Reduce Infection Deaths, said, "These infections kill as many people each year in our country as AIDS, breast cancer and auto accidents combined."
McCaughey said it's secrecy that's allowed the problem to grow. "Most states have not required hospitals to report their infections, or provide that information to the public," she said.
Pennsylvania is one of only six states that has passed a law requiring the reporting of infections. Experts say public disclosure forces hospitals to reduce infection rates. Dr. Rick Shannon, chief of medicine at Allegheny General Hospital in Pittsburgh, looked at the data on patients in the hospital's intensive care units. He was stunned.
"Fifty-one percent of everyone who got these infections died. Half the people who got one died," he said. Dr. Shannon wasted no time. He gave an order to the ICU staff. Reduce hospital infections to zero -- in just 90 days.
Staff nurses said they didn't think it could be done.
But after just one week, the ICU staff identified the culprit. It wasn't a superbug -- it was the staff. And the fact they each had their own way of washing hands, changing dressings, and putting in catheters. "No one actually knew what the right way to do it was. And not knowing what the right way to do it was that all these little errors could creep in that would lead to infection," Dr. Shannon said.
Dr. Shannon and his team quickly found solutions, like putting in more hand-sanitizers and raising the head of the bed 30 degrees to prevent pneumonia. The results were unbelievable.
"Ninety days later, we went from 49 infections to zero," he said.
And the results a year later are equally impressive. Only one patient in the ICU has died from an infection.
McCaughey says it's important for the public to know about infection rates at hospitals. "The public has a right to this information. If you are going into the hospital, you should be able to find out which hospital in your area has a serious infection problem, so you can stay away from that hospital," she said. Her advocacy group is working to pass more state laws -- like Pennsylvania's -- requiring hospitals to release this data.
And McCaughey says there's a simple thing you can do to keep yourself safe from dangerous germs in any hospital.
"Ask doctors and nurses to clean their hands before touching you. If you are worried about being too aggressive, just remember, your life is at stake," she said.
Read entire article at the original source
Hospital Infections Kill Tens of Thousands Every Year
ABC News
Oct. 14, 2005
There's a deadly threat hiding inside America's hospitals. What's even scarier, your hospital is probably keeping it a secret.
Maureen Daly's mother was a healthy 63-year-old woman when she had surgery to fix a broken shoulder. However, after being admitted to the hospital, Daly's mother got an infection that left her immobilized on a respirator. Daly was told that life-threatening germs are an inevitable fact of hospital life.
Daly was shocked. "I cannot accept that it would be a fact of life that you can walk into a hospital with a broken shoulder and leave practically dead," she said.
Her mother died four months later.
Betsy McCaughey, former lieutenant governor of New York and founder of the Committee to Reduce Infection Deaths, said, "These infections kill as many people each year in our country as AIDS, breast cancer and auto accidents combined."
McCaughey said it's secrecy that's allowed the problem to grow. "Most states have not required hospitals to report their infections, or provide that information to the public," she said.
Pennsylvania is one of only six states that has passed a law requiring the reporting of infections. Experts say public disclosure forces hospitals to reduce infection rates. Dr. Rick Shannon, chief of medicine at Allegheny General Hospital in Pittsburgh, looked at the data on patients in the hospital's intensive care units. He was stunned.
"Fifty-one percent of everyone who got these infections died. Half the people who got one died," he said. Dr. Shannon wasted no time. He gave an order to the ICU staff. Reduce hospital infections to zero -- in just 90 days.
Staff nurses said they didn't think it could be done.
But after just one week, the ICU staff identified the culprit. It wasn't a superbug -- it was the staff. And the fact they each had their own way of washing hands, changing dressings, and putting in catheters. "No one actually knew what the right way to do it was. And not knowing what the right way to do it was that all these little errors could creep in that would lead to infection," Dr. Shannon said.
Dr. Shannon and his team quickly found solutions, like putting in more hand-sanitizers and raising the head of the bed 30 degrees to prevent pneumonia. The results were unbelievable.
"Ninety days later, we went from 49 infections to zero," he said.
And the results a year later are equally impressive. Only one patient in the ICU has died from an infection.
McCaughey says it's important for the public to know about infection rates at hospitals. "The public has a right to this information. If you are going into the hospital, you should be able to find out which hospital in your area has a serious infection problem, so you can stay away from that hospital," she said. Her advocacy group is working to pass more state laws -- like Pennsylvania's -- requiring hospitals to release this data.
And McCaughey says there's a simple thing you can do to keep yourself safe from dangerous germs in any hospital.
"Ask doctors and nurses to clean their hands before touching you. If you are worried about being too aggressive, just remember, your life is at stake," she said.
Read entire article at the original source
Wednesday, December 07, 2005
Six Keys to Safer Hospitals
Six Keys to Safer Hospitals
Six Keys to Safer Hospitals
A set of simple precautions could prevent 100,000 needless deaths every year.
By Donald M. Berwick, M.D.
Newsweek, December 12, 2005
Sometime soon, I will need a new right knee. If all goes well, it will be quite a relief. An artificial joint can be a modern miracle, the alternative to decades of pain and hobbling. Here's the problem. Instead of helping me, health care might kill me. In 1999, the Institute of Medicine shocked the nation with an authoritative report on hospital errors. The report concluded that up to 98,000 Americans each year die in hospitals, not from the diseases that brought them there but from injuries caused by their medical care: preventable bleeding or infections, a medication mix-up, a respirator tube put in the wrong way and a lot more. I have climbed Mount Rainier five times. Each time I made that tough trek, my risk of dying was about 100 times smaller than the risk I will face on the operating table.
Even if the surgery doesn't kill me, it may still cause needless harm. The reason I need a new knee is that I have osteoarthritis?the result of a botched and unnecessary knee operation 30 years ago, when I was a naive and trusting medical student. What could go wrong this time? My postoperative pain may not be adequately controlled. I may receive the wrong dose of blood thinner, causing bleeding in my stomach. Someone may overlook the little patch of pneumonia on my routine postoperative chest X-ray, causing me to remain on a respirator in the intensive-care unit for several days. Or the hospital may fail to take steps that could prevent the pneumonia in the first place.
Fortunately, hospitals are beginning to realize that it doesn't have to be this way. On Dec. 14, 2004, the Institute for Healthcare Improvement, a nonprofit organization headquartered in Cambridge, Mass., launched the 100,000 Lives Campaign, a broad national effort to achieve the most urgent reforms. Mainstream leadership groups like the American Medical Association, the American Nurses Association and the Joint Commission on Accreditation of Healthcare Organizations immediately signed on to the campaign. Several federal agencies?including the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the Veterans Health Administration and the Agency for Healthcare Research and Quality?pledged support as well.
We have identified six basic measures that could save as many as 100,000 lives a year if even 2,000 hospitals adopted them. It's surprising to learn that these standards aren't already the norm?but the norms may finally be changing. Nearly 3,000 American hospitals have enrolled in our 100,000 Lives Campaign over the past year, and more than half are reporting their monthly death rates so that we (and they) can track progress. That takes courage in a world where hospitals, fearing blame and lawsuits, too often feel the need to hide their mistakes.
What exactly will it take to improve the quality of care? Here are the prescriptions that we and our partners are advancing. You don't have to be a doctor to understand them.
1 PREVENT RESPIRATOR PNEUMONIA
VAPs, or ventilator-associated pneumonias, are often deadly lung infections that people on respirators can get (after surgery, for example). A few simple maneuvers, like elevating the head of the hospital bed and frequently cleaning the patient's mouth, can eliminate them. Dominican Hospital in Santa Cruz, Calif., just celebrated one full year without a single VAP?a result most doctors would have thought impossible.
2 PREVENT IV-CATHETER INFECTIONS
Central-line infections occur when bacteria contaminate catheters that deliver food and medicine intravenously. Dr. Peter Pronovost of Johns Hopkins University recently reported that 70 hospitals in Michigan, California, Iowa and Indiana cut their central-line infections by half, saving an estimated $165 million from complications to boot. How did they do it? They made it easy for doctors and nurses to wash their hands between patients, adopted simple procedures for changing the bandages around the catheters and made absolutely sure that no catheter remained in a vein even one hour longer than needed.
3 STOP SURGICAL-SITE INFECTIONS
Surgical-site infections are a major cause of complications and deaths after operations. Last year Mercy Health Center in Oklahoma City operated on 1,200 consecutive patients without a single wound infection?by adopting a series of simple preventive measures. These include giving the right antibiotics at the right time during surgery, enforcing strict hand-washing and avoiding shaving the surgery site before the operation (clipping hair avoids nicking the skin and is safer).
4 RESPOND RAPIDLY TO EARLY-WARNING SIGNALS
A nurse or visitor is often the first person to notice that a patient is in trouble. By setting up special rapid-response teams, hospitals can ensure that these critical warnings are never missed or ignored. Busy physicians may resent the false alarms, but lives are saved when hospitals take nurses' concerns seriously and respond within minutes. Australian researchers have found that rapid-response teams may be able to cut hospital death rates by 20 percent or more. The University of Pittsburgh Medical Center is testing an even more innovative way to use rapid-response teams. The staff trains patients' visiting family members to call for assistance whenever they sense trouble. The new protocol, dubbed Condition H (for "Help"), has already saved lives.
5 MAKE HEART-ATTACK CARE ABSOLUTELY RELIABLE
The scientifically correct treatments for heart attacks could save far more lives if we used them reliably. The 100,000 Lives Campaign simply asks hospitals to ensure that every patient gets every medication and treatment recommended by the American College of Cardiology and other expert bodies. These measures include aspirin and a beta blocker on arrival and a stent or clot buster promptly after admission. McLeod Regional Medical Center in Florence, S.C., has cut the death rate among its heart-attack patients from 10 per-cent (the U.S. average) to about 4 percent. All the hospital had to do was ensure 100 percent reliability.
6 STOP MEDICATION ERRORS
Medication errors kill tens of thousands of patients a year, yet many are easily prevented. One secret is to "reconcile" medications whenever patients move from one care setting to another?from hospital to home, or even from one place to another within a hospital. The reconciliation protocol assigns a doctor or nurse at every step to check and recheck: are the medicines the patient gets after the transfer exactly the ones planned before the transfer? If not, the mistake gets corrected right away.
How much difference are we making through these efforts? We don't yet know whether the campaign will save 100,000 lives in its first year. Talk is cheap; changing the culture of a hospital is hard. But I've got a stake in it. When I close my eyes on the operating table so that a surgical team can implant my shiny new pain-free titanium knee, I know exactly what I want: safe, effective care, without a single complication.
BERWICK is president and CEO of the Institute for Healthcare Improvement (ihi.org) and clinical professor of pediatrics and health-care policy at Harvard Medical School. For more information, visit health.harvard.edu/NEWSWEEK.
Read the entire article at the original source
Six Keys to Safer Hospitals
A set of simple precautions could prevent 100,000 needless deaths every year.
By Donald M. Berwick, M.D.
Newsweek, December 12, 2005
Sometime soon, I will need a new right knee. If all goes well, it will be quite a relief. An artificial joint can be a modern miracle, the alternative to decades of pain and hobbling. Here's the problem. Instead of helping me, health care might kill me. In 1999, the Institute of Medicine shocked the nation with an authoritative report on hospital errors. The report concluded that up to 98,000 Americans each year die in hospitals, not from the diseases that brought them there but from injuries caused by their medical care: preventable bleeding or infections, a medication mix-up, a respirator tube put in the wrong way and a lot more. I have climbed Mount Rainier five times. Each time I made that tough trek, my risk of dying was about 100 times smaller than the risk I will face on the operating table.
Even if the surgery doesn't kill me, it may still cause needless harm. The reason I need a new knee is that I have osteoarthritis?the result of a botched and unnecessary knee operation 30 years ago, when I was a naive and trusting medical student. What could go wrong this time? My postoperative pain may not be adequately controlled. I may receive the wrong dose of blood thinner, causing bleeding in my stomach. Someone may overlook the little patch of pneumonia on my routine postoperative chest X-ray, causing me to remain on a respirator in the intensive-care unit for several days. Or the hospital may fail to take steps that could prevent the pneumonia in the first place.
Fortunately, hospitals are beginning to realize that it doesn't have to be this way. On Dec. 14, 2004, the Institute for Healthcare Improvement, a nonprofit organization headquartered in Cambridge, Mass., launched the 100,000 Lives Campaign, a broad national effort to achieve the most urgent reforms. Mainstream leadership groups like the American Medical Association, the American Nurses Association and the Joint Commission on Accreditation of Healthcare Organizations immediately signed on to the campaign. Several federal agencies?including the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the Veterans Health Administration and the Agency for Healthcare Research and Quality?pledged support as well.
We have identified six basic measures that could save as many as 100,000 lives a year if even 2,000 hospitals adopted them. It's surprising to learn that these standards aren't already the norm?but the norms may finally be changing. Nearly 3,000 American hospitals have enrolled in our 100,000 Lives Campaign over the past year, and more than half are reporting their monthly death rates so that we (and they) can track progress. That takes courage in a world where hospitals, fearing blame and lawsuits, too often feel the need to hide their mistakes.
What exactly will it take to improve the quality of care? Here are the prescriptions that we and our partners are advancing. You don't have to be a doctor to understand them.
1 PREVENT RESPIRATOR PNEUMONIA
VAPs, or ventilator-associated pneumonias, are often deadly lung infections that people on respirators can get (after surgery, for example). A few simple maneuvers, like elevating the head of the hospital bed and frequently cleaning the patient's mouth, can eliminate them. Dominican Hospital in Santa Cruz, Calif., just celebrated one full year without a single VAP?a result most doctors would have thought impossible.
2 PREVENT IV-CATHETER INFECTIONS
Central-line infections occur when bacteria contaminate catheters that deliver food and medicine intravenously. Dr. Peter Pronovost of Johns Hopkins University recently reported that 70 hospitals in Michigan, California, Iowa and Indiana cut their central-line infections by half, saving an estimated $165 million from complications to boot. How did they do it? They made it easy for doctors and nurses to wash their hands between patients, adopted simple procedures for changing the bandages around the catheters and made absolutely sure that no catheter remained in a vein even one hour longer than needed.
3 STOP SURGICAL-SITE INFECTIONS
Surgical-site infections are a major cause of complications and deaths after operations. Last year Mercy Health Center in Oklahoma City operated on 1,200 consecutive patients without a single wound infection?by adopting a series of simple preventive measures. These include giving the right antibiotics at the right time during surgery, enforcing strict hand-washing and avoiding shaving the surgery site before the operation (clipping hair avoids nicking the skin and is safer).
4 RESPOND RAPIDLY TO EARLY-WARNING SIGNALS
A nurse or visitor is often the first person to notice that a patient is in trouble. By setting up special rapid-response teams, hospitals can ensure that these critical warnings are never missed or ignored. Busy physicians may resent the false alarms, but lives are saved when hospitals take nurses' concerns seriously and respond within minutes. Australian researchers have found that rapid-response teams may be able to cut hospital death rates by 20 percent or more. The University of Pittsburgh Medical Center is testing an even more innovative way to use rapid-response teams. The staff trains patients' visiting family members to call for assistance whenever they sense trouble. The new protocol, dubbed Condition H (for "Help"), has already saved lives.
5 MAKE HEART-ATTACK CARE ABSOLUTELY RELIABLE
The scientifically correct treatments for heart attacks could save far more lives if we used them reliably. The 100,000 Lives Campaign simply asks hospitals to ensure that every patient gets every medication and treatment recommended by the American College of Cardiology and other expert bodies. These measures include aspirin and a beta blocker on arrival and a stent or clot buster promptly after admission. McLeod Regional Medical Center in Florence, S.C., has cut the death rate among its heart-attack patients from 10 per-cent (the U.S. average) to about 4 percent. All the hospital had to do was ensure 100 percent reliability.
6 STOP MEDICATION ERRORS
Medication errors kill tens of thousands of patients a year, yet many are easily prevented. One secret is to "reconcile" medications whenever patients move from one care setting to another?from hospital to home, or even from one place to another within a hospital. The reconciliation protocol assigns a doctor or nurse at every step to check and recheck: are the medicines the patient gets after the transfer exactly the ones planned before the transfer? If not, the mistake gets corrected right away.
How much difference are we making through these efforts? We don't yet know whether the campaign will save 100,000 lives in its first year. Talk is cheap; changing the culture of a hospital is hard. But I've got a stake in it. When I close my eyes on the operating table so that a surgical team can implant my shiny new pain-free titanium knee, I know exactly what I want: safe, effective care, without a single complication.
BERWICK is president and CEO of the Institute for Healthcare Improvement (ihi.org) and clinical professor of pediatrics and health-care policy at Harvard Medical School. For more information, visit health.harvard.edu/NEWSWEEK.
Read the entire article at the original source
Friday, October 21, 2005
Hospital infections are the fourth-leading cause of death in the United States
Myth: Hospitals Keep You Safe from Germs
Hospital Infections Kill Tens of Thousands Every Year
ABC News, Oct. 14, 2005
There's a deadly threat hiding inside America's hospitals. What's even scarier, your hospital is probably keeping it a secret.
Maureen Daly's mother was a healthy 63-year-old woman when she had surgery to fix a broken shoulder. However, after being admitted to the hospital, Daly's mother got an infection that left her immobilized on a respirator. Daly was told that life-threatening germs are an inevitable fact of hospital life.
Daly was shocked. "I cannot accept that it would be a fact of life that you can walk into a hospital with a broken shoulder and leave practically dead," she said.
Her mother died four months later. It turns out hospital infections are the fourth-leading cause of death in the United States.
Betsy McCaughey, former lieutenant governor of New York and founder of the Committee to Reduce Infection Deaths, said, "These infections kill as many people each year in our country as AIDS, breast cancer and auto accidents combined."
McCaughey said it's secrecy that's allowed the problem to grow. "Most states have not required hospitals to report their infections, or provide that information to the public," she said.
Pennsylvania is one of only six states that has passed a law requiring the reporting of infections. Experts say public disclosure forces hospitals to reduce infection rates. Dr. Rick Shannon, chief of medicine at Allegheny General Hospital in Pittsburgh, looked at the data on patients in the hospital's intensive care units. He was stunned.
"Fifty-one percent of everyone who got these infections died. Half the people who got one died," he said. Dr. Shannon wasted no time. He gave an order to the ICU staff. Reduce hospital infections to zero -- in just 90 days.
Staff nurses said they didn't think it could be done.
But after just one week, the ICU staff identified the culprit. It wasn't a superbug -- it was the staff. And the fact they each had their own way of washing hands, changing dressings, and putting in catheters. "No one actually knew what the right way to do it was. And not knowing what the right way to do it was that all these little errors could creep in that would lead to infection," Dr. Shannon said.
Dr. Shannon and his team quickly found solutions, like putting in more hand-sanitizers and raising the head of the bed 30 degrees to prevent pneumonia. The results were unbelievable.
"Ninety days later, we went from 49 infections to zero," he said.
And the results a year later are equally impressive. Only one patient in the ICU has died from an infection.
McCaughey says it's important for the public to know about infection rates at hospitals. "The public has a right to this information. If you are going into the hospital, you should be able to find out which hospital in your area has a serious infection problem, so you can stay away from that hospital," she said. Her advocacy group is working to pass more state laws -- like Pennsylvania's -- requiring hospitals to release this data.
And McCaughey says there's a simple thing you can do to keep yourself safe from dangerous germs in any hospital.
"Ask doctors and nurses to clean their hands before touching you. If you are worried about being too aggressive, just remember, your life is at stake," she said.
Read at the original source
Hospital Infections Kill Tens of Thousands Every Year
ABC News, Oct. 14, 2005
There's a deadly threat hiding inside America's hospitals. What's even scarier, your hospital is probably keeping it a secret.
Maureen Daly's mother was a healthy 63-year-old woman when she had surgery to fix a broken shoulder. However, after being admitted to the hospital, Daly's mother got an infection that left her immobilized on a respirator. Daly was told that life-threatening germs are an inevitable fact of hospital life.
Daly was shocked. "I cannot accept that it would be a fact of life that you can walk into a hospital with a broken shoulder and leave practically dead," she said.
Her mother died four months later. It turns out hospital infections are the fourth-leading cause of death in the United States.
Betsy McCaughey, former lieutenant governor of New York and founder of the Committee to Reduce Infection Deaths, said, "These infections kill as many people each year in our country as AIDS, breast cancer and auto accidents combined."
McCaughey said it's secrecy that's allowed the problem to grow. "Most states have not required hospitals to report their infections, or provide that information to the public," she said.
Pennsylvania is one of only six states that has passed a law requiring the reporting of infections. Experts say public disclosure forces hospitals to reduce infection rates. Dr. Rick Shannon, chief of medicine at Allegheny General Hospital in Pittsburgh, looked at the data on patients in the hospital's intensive care units. He was stunned.
"Fifty-one percent of everyone who got these infections died. Half the people who got one died," he said. Dr. Shannon wasted no time. He gave an order to the ICU staff. Reduce hospital infections to zero -- in just 90 days.
Staff nurses said they didn't think it could be done.
But after just one week, the ICU staff identified the culprit. It wasn't a superbug -- it was the staff. And the fact they each had their own way of washing hands, changing dressings, and putting in catheters. "No one actually knew what the right way to do it was. And not knowing what the right way to do it was that all these little errors could creep in that would lead to infection," Dr. Shannon said.
Dr. Shannon and his team quickly found solutions, like putting in more hand-sanitizers and raising the head of the bed 30 degrees to prevent pneumonia. The results were unbelievable.
"Ninety days later, we went from 49 infections to zero," he said.
And the results a year later are equally impressive. Only one patient in the ICU has died from an infection.
McCaughey says it's important for the public to know about infection rates at hospitals. "The public has a right to this information. If you are going into the hospital, you should be able to find out which hospital in your area has a serious infection problem, so you can stay away from that hospital," she said. Her advocacy group is working to pass more state laws -- like Pennsylvania's -- requiring hospitals to release this data.
And McCaughey says there's a simple thing you can do to keep yourself safe from dangerous germs in any hospital.
"Ask doctors and nurses to clean their hands before touching you. If you are worried about being too aggressive, just remember, your life is at stake," she said.
Read at the original source
Sunday, June 12, 2005
Coming Clean: Hospital infections kill an estimated 103,000 people in the United States a year
Coming Clean: Hospital infections kill an estimated 103,000 people in the United States a year
"Coming Clean
By BETSY MCCAUGHEY, The New York Times, June 6, 2005
INFECTIONS that have been nearly eradicated in some other countries are raging through hospitals here in the United States. The major reason? Poor hygiene. In fact, hygiene is so inadequate in most American hospitals that one out of every 20 patients contracts an infection during a hospital stay. Hospital infections kill an estimated 103,000 people in the United States a year, as many as AIDS, breast cancer and auto accidents combined.
And the danger is worsening as many hospital infections can no longer be cured with common antibiotics. One of the deadliest germs is a staph bacteria called M.R.S.A., short for methicillin-resistant Staphylococcus aureus, which lives harmlessly on the skin but causes havoc when it enters the body. Patients who do survive M.R.S.A. often spend months in the hospital and endure several operations to cut out infected tissue. In 1974, 2 percent of staph infections were from M.R.S.A. By 1995, that number had soared to 22 percent. Today, experts estimate that more than 60 percent of staph infections are M.R.S.A.
Hospitals in Denmark, Finland and the Netherlands once faced similar rates, but brought them down to below 1 percent. How? Through the rigorous enforcement of rules on hand washing, the meticulous cleaning of equipment and hospital rooms, the use of gowns and disposable aprons to prevent doctors and nurses from spreading germs on clothing and the testing of incoming patients to identify and isolate those carrying the germ.
Too few hospitals in the United States are using these precautions, though where they are used they are highly effective. In a pilot program, the veterans hospital in Pittsburgh reduced M.R.S.A. 85 percent, and the University of Virginia Medical Center eradicated it. Unfortunately most hospitals have not shown the will to defeat infections.
More than half the time, doctors and other caregivers break the most fundamental rule of hygiene by failing to clean their hands before treating a patient.
Hospital infections can be stopped, but most hospital administrators have not made prevention a top priority. The Centers for Disease Control and Prevention are also to blame. While the C.D.C. has made some efforts to curb hospital infections, they have failed to ask hospitals to follow the rigorous precautions that are working in other countries and in those American hospitals where they have been tried.
In 2003, a task force for the Society of Healthcare Epidemiologists of America chastised the C.D.C. for this failure, but the C.D.C. has still not acted. Every year of delay is costing thousands of lives.
Many hospital administrators say they can't afford to take the necessary precautions, but they can't afford not to. Infections erode hospital profits because rarely are hospitals fully paid for the added weeks or months that patients must spend in the hospital when they get an infection. Studies show that when hospitals invest in these proven precautions, they are rewarded with as much as tenfold financial return. These infections add about $30 billion annually to the nation's health costs. This tab will increase rapidly as more infections become drug-resistant.
In February, the Centers for Disease Control and Prevention declared that it will not support the growing demand to make hospital infection rates public. That's a shame because if you need to be hospitalized, you should be able to find out which hospitals in your area have the worst infection problems. This secrecy may allow some hospitals to save face, but it won't save lives or money."
Read the entire article
"Coming Clean
By BETSY MCCAUGHEY, The New York Times, June 6, 2005
INFECTIONS that have been nearly eradicated in some other countries are raging through hospitals here in the United States. The major reason? Poor hygiene. In fact, hygiene is so inadequate in most American hospitals that one out of every 20 patients contracts an infection during a hospital stay. Hospital infections kill an estimated 103,000 people in the United States a year, as many as AIDS, breast cancer and auto accidents combined.
And the danger is worsening as many hospital infections can no longer be cured with common antibiotics. One of the deadliest germs is a staph bacteria called M.R.S.A., short for methicillin-resistant Staphylococcus aureus, which lives harmlessly on the skin but causes havoc when it enters the body. Patients who do survive M.R.S.A. often spend months in the hospital and endure several operations to cut out infected tissue. In 1974, 2 percent of staph infections were from M.R.S.A. By 1995, that number had soared to 22 percent. Today, experts estimate that more than 60 percent of staph infections are M.R.S.A.
Hospitals in Denmark, Finland and the Netherlands once faced similar rates, but brought them down to below 1 percent. How? Through the rigorous enforcement of rules on hand washing, the meticulous cleaning of equipment and hospital rooms, the use of gowns and disposable aprons to prevent doctors and nurses from spreading germs on clothing and the testing of incoming patients to identify and isolate those carrying the germ.
Too few hospitals in the United States are using these precautions, though where they are used they are highly effective. In a pilot program, the veterans hospital in Pittsburgh reduced M.R.S.A. 85 percent, and the University of Virginia Medical Center eradicated it. Unfortunately most hospitals have not shown the will to defeat infections.
More than half the time, doctors and other caregivers break the most fundamental rule of hygiene by failing to clean their hands before treating a patient.
Hospital infections can be stopped, but most hospital administrators have not made prevention a top priority. The Centers for Disease Control and Prevention are also to blame. While the C.D.C. has made some efforts to curb hospital infections, they have failed to ask hospitals to follow the rigorous precautions that are working in other countries and in those American hospitals where they have been tried.
In 2003, a task force for the Society of Healthcare Epidemiologists of America chastised the C.D.C. for this failure, but the C.D.C. has still not acted. Every year of delay is costing thousands of lives.
Many hospital administrators say they can't afford to take the necessary precautions, but they can't afford not to. Infections erode hospital profits because rarely are hospitals fully paid for the added weeks or months that patients must spend in the hospital when they get an infection. Studies show that when hospitals invest in these proven precautions, they are rewarded with as much as tenfold financial return. These infections add about $30 billion annually to the nation's health costs. This tab will increase rapidly as more infections become drug-resistant.
In February, the Centers for Disease Control and Prevention declared that it will not support the growing demand to make hospital infection rates public. That's a shame because if you need to be hospitalized, you should be able to find out which hospitals in your area have the worst infection problems. This secrecy may allow some hospitals to save face, but it won't save lives or money."
Read the entire article
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