Why We Still Kill Patients: Invisibility, Inertia, And Income
December 6th, 2010
 by
Michael Millenson
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A recent front-page article in the New York Times conveyed grim news about patient safety. The first large-scale study of hospital safety in a decade concluded that care has not gotten significantly safer since the Institute of Medicine’s 1999 estimate of up to 98,000 preventable deaths and 1 million preventable injuries annually.
What for me struck a particularly jarring note was not just the
absence of improvement, but the reluctance of the health care leaders
interviewed to speak candidly about why progress has been so slow.
Instead, they offered nostrums about the need to “do more” or opined
that “openness” or better “coordination” would somehow turn the tide.
But tucked in the actual study’s conclusions section, between bland
boilerplate about “further study” and a “refocusing of resources,” some
carefully worded candor cautiously peeked through: “[T]he absence of
large-scale improvement is not evidence that current efforts to improve
safety are futile,” wrote Christopher Landrigan and colleagues in the
Nov. 25 New England Journal of Medicine. “On the contrary, data
have shown that focused efforts to reduce discrete harms, such as
nosocomial infections and surgical complications, can significantly
improve safety.”
In plain language, we know how to prevent many of these patient deaths, but we don’t. That makes, “Why?” a lot tougher question.
It is a question that has haunted me since I discovered that clear
descriptions of the medical error problem, its human cost and the
corrective actions needed began appearing in the medical literature in
the 1950s. The first large-scale study of hospital safety, by Don Harper Mills in California, was published in 1978. My extrapolation of its findings
showed a preventable national death rate of about 120,000 patients
annually. That’s roughly the same as the numbers from the oft-quoted Harvard Medical Practice Study published in 1991 that the IOM relied upon in its 1999 To Err is Human
report. In human terms it means that 2.5 million men, women, and
children died preventable deaths in U.S. hospitals during the 21 years
between 1978 and 1999. A staggering seven to 17 million suffered
preventable injuries.
The Silence Continues
I laid out those numbers in a March, 2003 Health Affairs article
that challenged the profession to break a silence of deed — failing to
take corrective actions — and a silence of word — failing to discuss
openly the consequences of that failure. This pervasive silence, I
wrote:
continually distorts the public policy debate [and] gives
individuals and institutions that must undergo difficult changes a
license to postpone them. Most seriously of all, it allows tens of
thousands of preventable patient deaths and injuries to continue to
accumulate while the industry only gradually starts to fix a problem
that is both long-standing and urgent.
Nearly eight years later, medical professionals now talk freely about
the existence of error and loudly about the need for combating it, but
silence about the extent of professional inaction and its causes remains
the norm. You can see it in this latest study, which decries the
continuing “patient-safety epidemic” while failing to do next what any
public health professional would instinctually do: tally up the toll.
Instead, we get dry language about the IOM’s goal of a 50 percent error
reduction over five years not being met.
Let’s fill in the blanks: If this unchecked “epidemic” were influenza
and not iatrogenesis, then from 1999 to date it would have killed the
equivalent of every man, woman and child in the cities of Raleigh (this
study took place in North Carolina) and Washington, D.C. Does a disaster
of that magnitude really suggest that “further study” and a “refocusing
of resources” are what’s needed?
Why are we still killing so many patients? Call it the “three I’s”: invisibility, inertia and income.
The invisibility issue is commonly articulated this way: while
airplane crashes kill a lot of people at once in a very public manner,
medical error kills a few people at a time in private, spread out among
thousands of hospitals. Moreover, most deaths occur among those who were
already very sick, and only a small proportion represent negligence.
This is inadvertent harm; there are no villains here. In any event,
medical care is complicated. As a result, as a 2009 JAMA commentary pointedly noted, “Clinicians have labeled virtually all harm as inevitable for decades.”
That conviction is conveyed to and largely believed by patients. Why
else would the advocacy groups for the sickest patients, such as the
American Cancer Society or American Diabetes Association, pay so little
attention to treatment-caused harm? Absent public or peer pressure,
doctors and hospitals are reluctant to adopt interventions whose
efficacy they mistrust to prevent an epidemic they really don’t see and
which is profoundly discomfiting to confront.
Letting Children Die Unnecessarily
There are many examples of the inertia these beliefs produce, but one
I cannot get out of my mind concerns sick children. At the 2009
AcademyHealth meeting, Dr. Richard Brilli of Nationwide Children’s
Hospital presented data showing how a collaborative backed by some of
the most respected organizations in pediatric care had slashed the rate
of catheter-associated bloodstream infections (CA-BSIs). CA-BSIs are
relatively common, very expensive and can be quite deadly (up to one
quarter of victims die). Brilli said his collaborative had tried to
recruit 330 pediatric intensive care units to join the initial
participants, but after three years, just sixty had accepted. The
reasons Brilli said he’s been given indicated to me that few had taken
the time to examine the collaborative’s methodology or results. Instead,
respondents asserted that their patients were sicker, their hospital
was busier than the others in the study, that joining would make them
look bad to others, or that the mortality reduction didn’t apply because
“I am in a world famous center.”
Now fast-forward to the February, 2010 issue of Pediatrics, in which the collaborative concluded: “CA-BSIs are a preventable cause of patient harm to critically ill
children.” What you can’t see in the peer-reviewed literature is this
context: at literally scores of hospitals which declined to participate
in the collaborative, hundreds of sick children likely were injured or
killed who probably would not have been harmed had the hospital been a
collaborative member. Those harmed were tended to by dedicated staff who
thought they were doing everything they could to help the kids in their
care. They were dead wrong, but even today they may not know it.
Certainly, their patients and the public do not.
I’ll cite just two other examples of inertia and invisibility
interacting to impede change. When the Institute for Healthcare
Improvement launched its “Save 100,000 Lives” Campaign
on the fifth anniversary of the IOM report (the delay speaks for
itself), four out of 10 U.S. hospitals still declined to participate. No
policymakers or commentators questioned why 40 percent of hospitals
would sit out this opportunity to improve care.
Another example: the Centers for Disease Control and Prevention
published its first hand-washing guidelines in 1975. Yet nearly 35 years
later, when the Joint Commission launched an improving hand hygiene
project, the eight hospitals that volunteered had a baseline hand
hygiene rate typical of hospitals nationwide: 48 percent. That’s worse than the worst rate at the worst big public men’s room in the United States,
according to one recent survey. But rather than giving providers an
ultimatum, we launch campaigns to ask patients to ask providers to
please wash up.
Most lethal of all is when invisibility and inertia interact with
income. Ironically, the modern patient safety movement owes its
foundational data to providers’ belief that malpractice insurance
premiums were too high. The landmark studies of medical error published
in 1978 and 1991 were backed by physician groups which hypothesized that
unjustified lawsuits, not actual medical problems, were driving up
premiums. In the event, research demonstrated that only a small
percentage of errors resulted in lawsuits and an even smaller percentage
in judgments. By that yardstick, the most recent study represents
progress, since it was motivated by care improvement rather than income
protection. Still, provider fear of being unjustly sued no doubt
obstructs needed sharing of information and argues for malpractice
reform.
Confronting The Belief That Complications Bring Extra Income
But there’s another elephant in the room that makes providers squirm
even more. Put bluntly, many hospital executives believe they make money
from complications. (Not from deaths, of course, because those shorten
length of stay). Frustrated clinicians have personally told me this many
times over the years, and as recently as a few weeks ago. The evidence
has even made its way into the medical literature.
To cite just one example, let’s go back to those expensive
bloodstream infections that affect the most vulnerable of patients,
critically ill children, being cared for at the most eleemosynary of
institutions, children’s hospitals. Even here, clinicians find
themselves forced to argue that there is a “business case” for reducing
CA-BSI’s in the pediatric intensive care unit.
In a recent journal article,
the authors framed their case this way: Yes, infections increased the
hospital stay by an average of nine days, and yes, insurers saved more
money than hospitals by eliminating them. However, if a hospital filled
the beds vacated by non-injured patients, it actually made more money
because new patients provided more revenue in the first few days than
tacking on those days to the hospital stay of patients already in the
ICU. A clinical and financial win-win!
The Unknown Success Story Of Ascension Health
The ultimate irony about the silence surrounding patient safety is
that one of the most extraordinary success stories in preventing harm
has largely gone unheard. Ascension Health looks like most of the U.S.
health care system, operating 65 community hospitals with independent
medical staffs. Yet its program to eliminate all preventable injuries or
deaths has been highly effective. They have carefully documented how
they reduced infections, falls, complications of childbirth and a host
of other common causes of patient harm to a fraction of national norms
and saved more than 2,000 lives every year.
The clinical and administrative leaders of Ascension Health, one of the nation’s largest Catholic health systems, made
the invisible visible, and found that errors were far more prevalent
than they thought. They declared that inertia would not be tolerated;
all their affiliated hospitals had to participate. And they were willing
to risk hospital income to prove that they were serious about change.
It is a story that so far seems to have excited only a few conference goers and regular readers of the Joint Commission Journal, which has been publishing articles about Ascension’s results since 2006.
As a society, we know what combination of social pressure, economic
incentives and provision of tools to enable new behavior lead to
transformational change. In patient safety we are using all of them,
including various public and private programs to refuse payment for
preventable error and publicize hospitals’ safety records.
But at the front lines of patient care, it is all too clear that these
efforts have yet to make much of a difference, as well-intentioned
professionals silently turn away from the preventable harm we are still
inflicting on those we are working so hard to help.
