US "healthcare": #3 killer

JAMA. 2003 Oct 8;290(14):1868-74.
Comment in: JAMA. 2003 Oct 8;290(14):1917-9.
Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.
Zhan C, Miller MR. Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, Md 20850, USA. czhan@ahrq.gov

  CONTEXT: Although medical injuries are recognized as a major hazard in the health care system, little is known about their impact.
  OBJECTIVE: To assess excess length of stay, charges, and deaths attributable to medical injuries during hospitalization.
  DESIGN, SETTING, AND PATIENTS: The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) were used to identify medical injuries in 7.45 million hospital discharge abstracts from 994 acute-care hospitals across 28 states in 2000 in the AHRQ Healthcare Cost and Utilization Project Nationwide Inpatient Sample database.
  MAIN OUTCOME MEASURES: Length of stay, charges, and mortality that were recorded in hospital discharge abstracts and were attributable to medical injuries according to 18 PSIs.
  RESULTS: Excess length of stay attributable to medical injuries ranged from 0 days for injury to a neonate to 10.89 days for postoperative sepsis, excess charges ranged from 0 dollar for obstetric trauma (without vaginal instrumentation) to $57,727 for postoperative sepsis, and excess mortality ranged from 0% for obstetric trauma to 21.96% for postoperative sepsis (P<.001). Following postoperative sepsis, the second most serious event was postoperative wound dehiscence, with 9.42 extra days in the hospital, $40,323 in excess charges, and 9.63% attributable mortality. Infection due to medical care was associated with 9.58 extra days, $38,656 dollars in excess charges, and 4.31% attributable mortality.
  CONCLUSION: Some injuries incurred during hospitalization pose a significant threat to patients and costs to society, but the impact of such injury is highly variable.

PMID: 14532315

  OBJECTIVE: The epidemiology of aspiration pneumonia and its impact on clinical and economic outcomes in surgical patients are poorly defined. We sought to identify preoperative patient characteristics and surgical procedures that are associated with an increased risk for aspiration pneumonia and to determine the clinical and economic impact in hospitalized surgical patients.
  DESIGN: Observational study using a state discharge database.
  SETTING: All hospitals in Maryland.
  PATIENTS: We obtained discharge data for 318,880 adult surgical patients in 52 Maryland hospitals from January 1, 1999, through December 31, 2000.
  MEASUREMENTS AND MAIN RESULTS: The primary outcome variable was a discharge diagnosis of aspiration pneumonia. Unadjusted and adjusted analyses were performed to identify patient characteristics and surgical procedures associated with an increased risk for aspiration pneumonia and to determine the impact on intensive care unit admission, in-hospital mortality, hospital length of stay, and total hospital charges. The overall prevalence of aspiration pneumonia was 0.8%. The prevalence varied among hospitals (range, 0% to 1.9%) and by surgical procedure (range, <0.1% to 19.1%). Patient characteristics independently associated with an increased risk included: male sex, nonwhite race, age of >60 yrs vs. 18-29 yrs, dementia, chronic obstructive pulmonary disease, renal disease, malignancy, moderate to severe liver disease, and emergency room admission. In patients undergoing procedures other than tracheostomy, aspiration pneumonia was independently associated with an increased risk for admission to the intensive care unit (odds ratio, 4.0; 95% confidence interval, 3.0-5.1), in-hospital mortality (odds ratio, 7.6; 95% confidence interval, 6.5-8.9), longer hospital length of stay (estimated mean increase of 9 days; 95% confidence interval, 8-10), and increased total hospital charges (estimated mean increase of 22,000 US dollars; 95% confidence interval, 19,000 US dollars-25,000 US dollars).
  CONCLUSIONS: Aspiration pneumonia occurs in approximately 1% of surgical patients and is associated with significant morbidity, mortality, and costs of care. Given that the rate of aspiration pneumonia varies among hospitals, we can improve the quality and reduce the costs of care by implementing strategies to reduce the rate of aspiration pneumonia.

PMID: 12847385

  OBJECTIVE: Our objective was to describe potential patient safety events for hospitalized children, using the patient safety indicators (PSIs), and examine associations with these events.
  METHODS: PSI algorithms, developed by researchers at the Agency for Healthcare Research and Quality to identify potential in-hospital patient safety problems using administrative data, were applied to 3.8 million discharge records for children under 19 years from 22 states in the 1997 Healthcare Cost and Utilization Project. Prevalence of PSI events and associations with patient-level and hospital-level characteristics, length of stay, in-hospital mortality, and total charges were examined.
  RESULTS: The prevalence of pediatric patient safety events is significant with the highest rate found for birth trauma at 1.5 cases per every 100 births. The majority of these events for birth trauma consist of long bone and skull fractures, excluding the clavicle. Compared with records without PSI events, discharges with PSI events had 2- to 6-fold longer lengths of stay, 2- to 18-fold higher rates of in-hospital mortality, and 2- to 20-fold higher total charges. Bivariate and multivariate analyses found that all PSI events except birth trauma were directly associated with factors related to greater severity of illness and large urban teaching institutions. Birth trauma, however, was directly associated with black and Hispanic ethnicity but was not consistently associated with technologically sophisticated teaching institutions.
   CONCLUSIONS: The prevalence of birth trauma and other potential patient safety events for hospitalized children is high and comparable to hospitalized adults. These events are associated with increased length of stay, in-hospital mortality, and total charges. Associated factors differ significantly for birth trauma compared with other PSI events. Institutional application of the PSIs may be useful to identify processes of care that warrant further evaluation as the health care industry tackles the problem of patient safety, particularly for children.

PMID: 12777553

  OBJECTIVE: To measure the impact of orthopedic surgical-site infections (SSIs) on quality of life, length of hospitalization, and cost.
  DESIGN: A pairwise-matched (1:1) case-control study within a cohort.
  SETTING: A tertiary-care university medical center and a community hospital.
  PATIENTS: Cases of orthopedic SSIs were prospectively identified by infection control professionals. Matched controls were selected from the entire cohort of patients undergoing orthopedic surgery who did not have an SSI. Matching variables included type of surgical procedure, National Nosocomial Infections Surveillance risk index, age, date of surgery, and surgeon.
  MAIN OUTCOME MEASURES: Quality of life, duration of postoperative hospital stay, frequency of hospital readmission, overall direct medical costs, and mortality rate.
  RESULTS: Fifty-nine SSIs were identified. Each orthopedic SSI accounted for a median of 1 extra day of stay during the initial hospitalization (P = .001) and a median of 14 extra days of hospitalization during the follow-up period (P = .0001). Patients with SSI required more rehospitalizations (median, 2 vs 1; P = .0001) and more total surgical procedures (median, 2 vs 1; P = .0001). The median total direct cost of hospitalizations per infected patient was $24,344, compared with $6,636 per uninfected patient (P = .0001). Mortality rates were similar for cases and controls. Quality of life was adversely affected for patients with SSI. The largest decrements in scores on the Medical Outcome Study Short Form 36 questionnaire were seen in the physical functioning and role-physical domains.
  CONCLUSIONS: Orthopedic SSIs prolong total hospital stays by a median of 2 weeks per patient, approximately double rehospitalization rates, and increase healthcare costs by more than 300%. Moreover, patients with orthopedic SSIs have substantially greater physical limitations and significant reductions in their health-related quality of life.

PMID: 12002232

  Information concerning the deficiencies of US medical care has been accumulating. The fact that more than 40 million people have no health insurance is well known. The high cost of the health care system is considered to be a deficit, but seems to be tolerated under the assumption that better health results from more expensive care, despite evidence from a few studies indicating that as many as 20% to 30% of patients receive contraindicated care.[1] In addition, with the release of the Institute of Medicine (IOM) report: "To Err Is Human,"[2] millions of Americans learned, for the first time, that an estimated 44,000 to 98,000 among them die each year as a result of medical errors.

  The fact is that the US population does not have anywhere near the best health in the world. Of 13 countries in a recent comparison, the United States ranks an average of 12th (second from the bottom) for 16 available health indicators. Countries in order of their average ranking on the health indicators (with the first being the best) are Japan, Sweden, Canada, France, Australia, Spain, Finland, the Netherlands, the United Kingdom, Denmark, Belgium, the United States, and Germany. Rankings of the United States on the separate indicators[3a] are:

13th (last) for low-birth-weight percentages
13th for neonatal mortality and infant mortality overall
11th for postneonatal mortality
13th for years of potential life lost (excluding external causes)
11th for life expectancy at 1 year for females, 12th for males
10th for life expectancy at 15 years for females, 12th for males
10th for life expectancy at 40 years for females, 9th for males
7th for life expectancy at 65 years for females, 7th for males
3rd for life expectancy at 80 years for females, 3rd for males
10th for age-adjusted mortality

  The poor performance of the United States was recently confirmed by the World Health Organization, which used different indicators. Using data on disability-adjusted life expectancy, child survival to age 5 years, experiences with the health care system, disparities across social groups in experiences with the health care system, and equality of family out-of-pocket expenditures for health care (regardless of need for services), this report ranked the United States as 15th among 25 industrialized countries.[4] Thus, the figures regarding the poor position of the United States in health worldwide are robust and not dependent on the particular measures used. Common explanations for this poor performance fail to implicate the health system. The perception is that the American public "behaves badly" by smoking, drinking, and perpetrating violence. The data show otherwise, at least relatively. The proportion of females who smoke ranges from 14% in Japan to 41% in Denmark; in the United States, it is 24% (fifth best). For males, the range is from 26% in Sweden to 61% in Japan; it is 28% in the United States (third best).

  The data for alcoholic beverage consumption are similar: the United States ranks fifth best. Thus, although tobacco use and alcohol use in excess are clearly harmful to health, they do not account for the relatively poor position of the United States on these health indicators. The data on years of potential life lost exclude external causes associated with deaths due to motor vehicle collisions and violence, and it is still the worst among the 13 countries.[3b] Dietary differences have been demonstrated to be related to differences in mortality across countries,[5] but the United States has relatively low consumption of animal fats (fifth lowest in men aged 55-64 years in 20 industrialized countries) and the third lowest mean cholesterol concentrations among men aged 50 to 70 years among 13 industrialized countries.[6]

  The real explanation for relatively poor health in the United States is undoubtedly complex and multifactorial. From a health system viewpoint, it is possible that the historic failure to build a strong primary care infrastructure could play some role. A wealth of evidence[3c] documents the benefits of characteristics associated with primary care performance. Of the 7 countries in the top of the average health ranking, 5 have strong primary care infrastructures. Although better access to care, including universal health insurance, is widely considered to be the solution, there is evidence that the major benefit of access accrues only when it facilitates receipt of primary care.[3, 7] The health care system also may contribute to poor health through its adverse effects. For example, US estimates[8, 9, 10] of the combined effect of errors and adverse effects that occur because of iatrogenic damage not associated with recognizable error include:

12,000 deaths/year from unnecessary surgery
7000 deaths/year from medication errors in hospitals
20,000 deaths/year from other errors in hospitals
80,000 deaths/year from nosocomial infections in hospitals
106,000 deaths/year from nonerror, adverse effects of medications

  These total to 225,000 deaths per year from iatrogenic causes. Three caveats should be noted. First, most of the data are derived from studies in hospitalized patients. Second, these estimates are for deaths only and do not include adverse effects that are associated with disability or discomfort. Third, the estimates of death due to error are lower than those in the IOM report. If the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000. In any case, 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. Even if these figures are overestimated, there is a wide margin between these numbers of deaths and the next leading cause of death (cerebrovascular disease).

  One analysis overcomes some of these limitations by estimating adverse effects in outpatient care and including adverse effects other than death. It concluded that between 4% and 18% of consecutive patients experience adverse effects in outpatient settings, with 116 million extra physician visits, 77 million extra prescriptions, 17 million emergency department visits, 8 million hospitalizations, 3 million long-term admissions, 199,000 additional deaths, and $77 billion in extra costs (equivalent to the aggregate cost of care of patients with diabetes).[11]

  Another possible contributor to the poor performance of the United States on health indicators is the high degree of income inequality in this country. An extensive literature documents the enduring adverse effects of low socioeconomic position on health; a newer and accumulating literature suggests the adverse effects not only of low social position but, especially, low relative social position in industrialized countries.[12] Among the 13 countries included in the international comparison mentioned above, the US position on income inequality is 11th (third worst). Sweden ranks the best on income equality (when income is calculated after taxes and including social transfers), matching its high position for health indicators. There is an imperfect relationship between rankings on income inequality and health, although the United States is the only country in a poor position on both (B.S., unpublished data, 2000).

  An intriguing aspect of the data is the differences in ranking for the different age groups. US children are particularly disadvantaged, whereas elderly persons are much less so. Judging from the data on life expectancy at different ages, the US population becomes less disadvantaged as it ages, but even the relatively advantaged position of elderly persons in the United States is slipping. The US relative position for life expectancy in the oldest age group was better in the 1980s than in the 1990s.[13] The long-existing poor ranking of the United States with regard to infant mortality[14] has been a cause for concern; it is not a result of the high percentages of low birth weight and infant mortality among the black population, because the international ranking hardly changes when data for the white population only are used.

  Whereas definitive explanations for the relatively poor position of the United States continue to be elusive, there are sufficient hints as to their nature to provide the basis for consideration of neglected factors:

  (1) The nature and operation of the health care system. In the United States, in contrast to many other countries, the extent to which receipt of services from primary care physicians vs specialists affects overall health and survival has not been considered. While available data indicate that specialty care is associated with better quality of care for specific conditions in the purview of the specialist,[15]the data on general medical care suggest otherwise.[16] National surveys almost all fail to obtain data on the extent to which the care received fulfills the criteria for primary care, so it is not possible to examine the relationships between individual and community health characteristics and the type of care received.

  (2) The relationship between iatrogenic effects (including both error and nonerror adverse events) and type of care received. The results of international surveys document the high availability of technology in the United States. Among 29 countries, the United States is second only to Japan in the availability of magnetic resonance imaging units and computed tomography scanners per million population.[17] Japan, however, ranks highest on health, whereas the United States ranks among the lowest. It is possible that the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the United States, high use of diagnostic technology may be linked to the "cascade effect"[18] and to more treatment. Supporting this possibility are data showing that the number of employees per bed (full-time equivalents) in the United States is highest among the countries ranked, whereas they are very low in Japan[17]far lower than can be accounted for by the common practice of having family members rather than hospital staff provide the amenities of hospital care.

  How cause of death and outpatient diagnoses are coded does not facilitate an understanding of the extent to which iatrogenic causes of ill health are operative. Consistent use of "E" codes (external causes of injury and poisoning) would improve the likelihood of their recognition because these ICD (International Classification of Diseases) codes permit attribution of cause of effect to "Drugs, Medicinal, and Biological Substances Causing Adverse Effects in Therapeutic Use." More consistent use of codes for "Complications of Surgical and Medical Care" (ICD codes 960-979 and 996-999) might improve the recognition of the magnitude of their effect; currently, most deaths resulting from these underlying causes are likely to be coded according to the immediate cause of death (such as organ failure). The suggestions of the IOM document on mandatory reporting of adverse effects might improve reporting in hospital settings, but it is unlikely to affect underreporting of adverse events in noninstitutional settings. Only better record keeping, with documentation of all interventions and resulting health status (including symptoms and signs), is likely to improve the current ability to understand both the adverse and positive effects of health care.

  (3) The relationships among income inequality, social disadvantage, and characteristics of health systems, including the relative contributions of primary care and specialty care. Recent studies using physician-to-population ratios (as a proxy for unavailable data on actual receipt of health services according to their type) have shown that the higher the primary care physician–to–population ratio in a state, the better most health outcomes are.[19] The influence of specialty physician–to–population ratios and of specialist–to–primary care physician ratios has not been adequately studied, but preliminary and relatively superficial analyses suggest that the converse may be the case. Inclusion of income inequality variables in the analysis does not eliminate the positive effect of primary care. Furthermore, states that have more equitable distributions of income also are more likely to have better primary care resource availability, thus raising questions about the relationships among a host of social and health policy characteristics that determine what and how resources are available.

  Recognition of the harmful effects of health care interventions, and the likely possibility that they account for a substantial proportion of the excess deaths in the United States compared with other comparably industrialized nations, sheds new light on imperatives for research and health policy. Alternative explanations for these realities deserve intensive exploration.

Author/Article Information Author Affiliation: Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, Baltimore, Md.

Corresponding Author and Reprints: Barbara Starfield, MD, MPH, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, 624 N Broadway, Room 452, Baltimore, MD 21205-1996 (e-mail).

REFERENCES

[1] Schuster M, McGlynn E, Brook R. How good is the quality of health care in the United States? Milbank Q. 1998;76:517-563. MEDLINE

[2] Kohn L, ed, Corrigan J, ed, Donaldson M, ed. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

[3a]
[3b]
[3c] Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press; 1998.

[4] World Health Report 2000. Available

[5] Kunst A. Cross-national Comparisons of Socioeconomic Differences in Mortality. Rotterdam, the Netherlands: Erasmus University; 1997.

[6] Law M, Wald N. Why heart disease mortality is low in France: the time lag explanation. BMJ. 1999;313:1471-1480.

[7] Starfield B. Evaluating the State Children's Health Insurance Program: critical considerations. Annu Rev Public Health. 2000;21:569-585. MEDLINE

[8] Leape L. Unnecessary surgery. Annu Rev Public Health. 1992;13:363-383.

[9] Phillips D, Christenfeld N, Glynn L. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-644.

[10] Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205. MEDLINE

[11] Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology and medical error. BMJ. 2000;320:774-777.

[12] Wilkinson R. Unhealthy Societies: The Afflictions of Inequality. London, England: Routledge; 1996.

[13] Evans R, Roos N. What is right about the Canadian health system? Milbank Q. 1999;77:393-399. MEDLINE

[14] Guyer B, Hoyert D, Martin J, Ventura S, MacDorman M, Strobino D. Annual summary of vital statistics1998. Pediatrics. 1999;104:1229-1246. MEDLINE

[15] Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14:499-511. MEDLINE

[16] Donahoe MT. Comparing generalist and specialty care: discrepancies, deficiencies, and excesses. Arch Intern Med. 1998;158:1596-1607. MEDLINE

[17] Anderson G, Poullier J-P. Health Spending, Access, and Outcomes: Trends in Industrialized Countries. New York, NY: The Commonwealth Fund; 1999.

[18] Mold J, Stein H. The cascade effect in the clinical care of patients. N Engl J Med. 1986;314:512-514.

[19] Shi L, Starfield B. Income inequality, primary care, and health indicators. J Fam Pract. 1999;48:275-284. MEDLINE

© 2000 American Medical Association. All rights reserved.

  "The Institute of Medicine's 1999 report suggested that medical errors accounted for 44,000-98,000 deaths each year.[Note: previous article claimed only 7,000, so the reporting method seems to be rather inaccurate ljf] These deaths exceed the eighth leading cause of death in the United States. It is estimated that the total cost of medical errors is $17 - $29 billion annually. [However, this figure is given as "exceeded $177.4 billion" in 2000 in another article ljf] Although the percentage of drug-related medical errors in ambulatory settings is unknown, drugs are the most common cause of medical errors in hospitals, affecting 3.7% of patients. Clearly, medication errors are a significant component of medical errors in U.S. hospitals. ... we could not determine the specific types of medication errors. Nor could we gather specific information about each medication error and the types of harm experienced by patients. Unfortunately, there is no national standard that hospitals use to categorize medication errors. Since medication errors were likely underreported, actual error rates were likely higher than reported.

     Yet another article claims "Case reports of medication errors from hospitals, ambulatory care settings, and patients' homes that were entered in FDA's Adverse Event Reporting System during 1993- 98 were the source of information on fatal medication errors." "The data indicated 5366 medication error reports. Fifty-nine reports were excluded and classified as duplicate reports or intentional overdoses. Of the remaining medication error reports, 68.2% resulted in serious patient outcomes and 9.8% were fatal. Of the 469 fatal medication error reports, 48.6% occurred in patients over 60 years. The most common types of errors resulting in patient death involved administering an improper dose (40.9%), administering the wrong drug (16%), and using the wrong route of administration (9.5%). The most common causes of errors were performance and knowledge deficits (44%) and communication errors (15.8%). Fatal medication errors accounted for approximately 10% of medication errors reported to FDA and were most frequently the result of improper dosing of the intended drug and administration of an incorrect drug."

     So, this report claims there were ~ 520 deaths in a 5 year period, thus ~ 104 drug deaths per year.  Yet the first article on this page reports "7000 deaths/year from medication errors in hospital", and another "106,000 deaths/year from nonerror, adverse effects of medications" bringing drug-related deaths up to 113,000 per year.

     The only conclusion to be drawn is that the reporting of iatrogenic deaths is in need of a serious overhaul, and that accurate information of the hazards of the Medical System is not available to the public.

Medscape General Medicine Editorial
American Health System Reform: Circa 2001-2002 George D. Lundberg, MD
[MedGenMed, October 22, 2001. © 2001 Medscape, Inc.]

  Beginning in the mid to late 1980s, many worked hard individually and in groups to try to achieve meaningful comprehensive American health system reform. The zenith of such activities followed the election in 1992 of a majority-Democratic US Senate and House of Representatives, along with a Democratic President and Vice President elected on a platform that highlighted health system reform with health insurance for all Americans. Reform seemed a cinch, but we all know that the Clinton Plan was ill-conceived and ill-fated, virtually dead on arrival in 1993.
  The nadir of organized health reform efforts promptly followed the collapse of the Clinton Plan. It took several years before work by Karen Donelan and others, funded by the Kaiser Family Foundation and published in JAMA in 1996,[1] once again placed the plight of the uninsured back on America's public radar screen, alas to no immediate avail.
  But health system reform did not just stop with the Clinton Plan failure. It proceeded at breakneck speed, powered by the "medical marketplace forces." We experienced a rapid takeover of the healthcare field with its professional and service orientations by a for-profit industry led by bottom line-oriented managed-care organizations and health insurance companies. Politicians deigned to interfere, recalling the terrible voter backlash against the Clinton Plan that was wreaked by the Republicans. Organized medicine was strangely silent and ineffective as this business takeover of a profession ran rampant for the better part of the 1990s.
  In this virtually unregulated environment, for-profit forces had their way with the American people. In point of fact, costs had grown completely out of control by the late 1980s and nothing worked to constrain them. We as a society have a lot of justifiable faith in "the market" to fix a lot of problems. So I suppose the managed care experiment, although not planned, could be considered justified. The movement was designed to squeeze out the system's many existing inefficiencies, actually turn healthcare inflation around, and at the same time make a lot of money for the owners, investors, and highest level workers, while theoretically providing improved quality of care and prevention of disease.
  As it turns out, some of that actually did happen. Costs were contained for several years. Many people got very rich off of the for-profit business, early on. But that was then, and this is now. For-profit managed care in America is now over. It was a short-term partial success and a long-term abject failure. It now devolves to us to figure out what we should do in the post managed care era.
  After James Stacey and I wrote Severed Trust: Why American Medicine Has Not Been Fixed (Basic Books, 2001), many with whom we spoke registered surprise at our observations and ideas. But in the short span of 8 months, these ideas seem to have gained currency. At least 4 congruent efforts are under way from widely disparate sources to try to again move the American system in the direction of meaningful comprehensive reform.
  Accompanying this editorial in Medscape General Medicine today is a speech by Paul M. Ellwood, Jr., MD, given at the University of California at Irvine on October 2, 2001.[2] Readers may recall that Paul created the concept of the Health Maintenance Organization (HMO) around 1965. He was the leader of the famed Jackson Hole Group, which operated on an ad hoc basis for the better part of 20 years. In his speech, Ellwood summarizes these efforts and expresses his dismay about how the whole managed care scene has eventuated. But most importantly, Ellwood has once again shown signs of entering the fray and provides in Medscape General Medicine his proposal for the direction reform should head. A proponent of the catchy phrase or acronym to help learning and memory, he now proposes HEROIC as the way for our country to proceed.
  In Ellwood's proposed schema:
H stands for HEALTH SYSTEM
E for EVIDENCE-BASED MEDICINE
R for RESPONSIBILITY -- ESPECIALLY OF PATIENTS
O for OUTCOMES ACCOUNTABILITY
I for INFORMATION TECHNOLOGY
C for COMMITMENT
  Ellwood proposes that this set of elements provide the framework for a new US healthcare system.
  Second, a health economist named Brian R. Klepper, PhD, from Jacksonville, Florida, has organized a group called the Center for Practical Health Reform (CPHR). An advisory group of some 40 individuals, many quite notable, from a wide range of (mostly) health organizations, have agreed to work with him. They share the belief that our healthcare "system," such as it is, is in danger of imminent collapse, and they would rather save it than have it go under and have to be rebuilt from scratch. A recent press release describing the make-up, purpose, and 7 guiding principles of this group as well as a list of some of the main players is available at www.practicalhealthreform.org.
  Their principles for change are:
Basic coverage for all Americans.
For those who want and can afford it, the ability to afford choice.
Private sector health management, with financial incentives for performance and innovation.
Adoption of scientifically developed best practice guidelines.
Publicly available performance information on professionals, institutions, and procedures.
More individual financial responsibility for unhealthy lifestyle choices and demands for service beyond medical protocol.
Longer health plan relationships.
  In the third effort, medical economist J. D. Kleinke, a long-time outspoken proponent of health reform led by managed care, has just released a new book called Oxymorons: The Myth of a US Health Care System (Jossey-Bass, 2001). In it, Kleinke changes his tune dramatically, instead now blaming managed care for a system run amuck and charging that private medical marketplace forces have aggravated rather than alleviated the economic, access, and quality problems of the system. In this analysis, the author belatedly makes the well-known observation that the US healthcare marketplace does not resemble a real marketplace. Correctly noting that all the players have their own economic agendas, which are frequently in conflict, Kleinke states that there is "40 cents of our health care dollar consumed by insurers and providers in an administrative grudge-match over the other 60 cents."
  Kleinke's fix includes a mix of the marketplace fixing what it can fix, regulators fixing what the marketplace cannot fix, and individuals doing more for themselves, all in an environment changed by a simple rewriting of the US tax code so that healthcare or health insurance is paid for with pretax dollars to level the playing field and install reasonable incentives for efficiency.
  Essentially all of the foregoing ideas are brought forward in Severed Trust, which describes how we got into the mess we are in by well meaning but ultimately flawed policy decisions dating from the second World War. The second edition of Severed Trust is expected to be available in paperback form from Basic Books in March 2002. Its new 11th chapter expands upon these 6 basic principles:
  Don't mess with Medicare. Medicare is a huge success and could be improved somewhat by tinkering (such as a prescription drug benefit) but mostly should be retained as is.
  All Americans must have basic health insurance coverage. This could best be accomplished by federal imposition of an individual mandate. Individuals could then obtain their health insurance from their (or their spouse's or significant other's) employer, from Medicare, from Medicaid, by a system of tax credits or by direct personal purchase. The cost of premiums should be means-based as well as related to nature of benefits.
  Most cost control should be exerted by informed consumers, through a means-based high annual deductible and out-of-pocket pay for most ambulatory care. In nonemergency situations, physicians should explain in advance what something will cost (no matter who is paying the bill) and the patient should give an economic informed consent prior to incurring the expense. In short, doctors and patients should decide together whether something is worth the money, after the reasons for the cost have been conveyed transparently. Most hospital (catastrophic) costs would exceed the annual deductible and thus be paid entirely by the insurer. There would be no lifetime maximums.
  Scientifically proven prevention measures [vegan diet? - ljf] should be defined as part of public health and thus paid for entirely by government as being in the nation's best interests.
  Quality and safety concerns should be acknowledged as serious, and the recent reports of the Institute of Medicine on each topic should be recognized as the definitive treatments of both issues and implemented very much as prescribed.
  These 4 separately developed sweeping proposals for the next American Healthcare System possess a remarkable confluence of flow and substance. The people espousing them spring from all regions of the United States, from inside and outside the profession and the business of medicine, and from people who would not see their ideas as aligned with any particular political position or party. The authors are all Americans who care greatly about their country and about the health of our people and know that we can do much better than we now are doing. The old system is over. We can provide better access, quality, and safety at less expense in a new healthcare system, if we but work together using our best minds and motives.
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References
[1] Donelan K, Blendon RJ, Hill CA, et al. Whatever happened to the health insurance crisis in the United States? Voices from a national survey. JAMA. 1996;276:1346-1350.

[2] Ellwood PM. Does Managed Care Need to be Replaced? Presentation to the Graduate School of Management, University of California, Irvine, October 2, 2001. Medscape General Medicine October 19, 2001.

  Objective. To describe the prevalence of potentially inappropriate medication (PIM) use (defined by the Beers criteria) and association with resource utilization in a Medicare managed care population.
  Methods. Retrospective review of a health maintenance organization (HMO) administrative database claims data for a subset of Medicare managed care patients 65 years of age and older to compare persons on PIMs (cases) with persons not on PIMs (comparisons). Measures included costs, inpatient and outpatient utilization, number of prescriptions, patient demographics, diagnoses, prescriber information, clinical data including self-rated health, and the Charlson Comorbidity Index.
  Results. The prevalence of PIM use in this Medicare managed care population was 24.2% (541/2,336). Eighty-eight of the 146 individuals on two or more inappropriate medications had 4-13 providers prescribing all their medications. Those on a PIM had significantly higher total, provider, and facility costs, and a higher mean number of inpatient, outpatient, and emergency room visits than comparisons after controlling for sex, Charlson comorbidity index, and total number of prescriptions.
  Conclusions. Our study revealed a high prevalence of potentially inappropriate medication use among older adults in a managed care plan and an association with high resource utilization. In this study, we sought to gather evidence to guide the future development of an intervention and educational program to decrease the use of high-risk medications in older adults.
Full article: J Managed Care Pharm 7(5):407-413, 2001.
© 2001 Academy of Managed Care Pharmacy, Inc.]

  CONTEXT: Substantial effort has been devoted to improving physician compliance with evidence-based guidelines.
  OBJECTIVE: To explore physicians' reasons for not following so-called "best practices" in caring for patients with type 2 diabetes.
  DESIGN: Descriptive study of self-assessed compliance with five measures of performance.
  PARTICIPANTS: Eighty-five internists who volunteered to participate in a practice-based research network created to improve clinical practice.
  DATA COLLECTION: Physicians reviewed their own charts of patients with type 2 diabetes mellitus (1755 patient encounters) to assess compliance and offered open-ended comments concerning their reasons for not complying with "best practices."
  RESULTS: The physician volunteers reported not complying with the annual foot examination in 13% of encounters. A similar level of noncompliance was reported for the annual lipid profile (15%) and retinal examination (17%). Among the five measures examined, noncompliance was most common for screening urinalysis (26%) and screening microalbuminuria (46%). The physicians' open-ended comments suggested that physician oversight, patient nonadherence, and systems issues were common reasons for noncompliance. However, noncompliance also resulted from a conscious decision by the physician, as indicated by comments about patient age and comorbid illness or, with nephropathy screening, established renal disease or current therapy with angiotensin-converting enzyme inhibitors.
  CONCLUSIONS: Even among a self-selected group of physicians, noncompliance with best practices in diabetes is common. Although physician forgetfulness and external factors are frequently offered as reasons for noncompliance, it may also result from a conscious decision, as physicians may disagree about what constitutes "best practices."

PMID: 11685978