In a 2000 JAMA article, Dr. Barbara Starfield presents well-documented facts that are both shocking and unassailable.19,20 The US ranks 12th of 13 industrialized countries when judged by 16 health status indicators. Japan, Sweden, and Canada were first, second, and third, respectively. More than 40 million people in the US have no health insurance, and 20-30% of patients receive contraindicated care.
Starfield warned that one cause of medical mistakes is overuse of technology, which may create a “cascade effect” leading to still more treatment. She urges the use of ICD (International Classification of Diseases) codes that have designations such as “Drugs, Medicinal, and Biological Substances Causing Adverse Effects in Therapeutic Use” and “Complications of Surgical and Medical Care” to help doctors quantify and recognize the magnitude of the medical error problem. Starfield notes that many deaths attributable to medical error today are likely to be coded to indicate some other cause of death. She concludes that against the backdrop of our poor health report card compared to other Western countries, we should recognize that the harmful effects of health care interventions account for a substantial proportion of our excess deaths.
Starfield cites Weingart’s 2000 article, “Epidemiology of Medical Error,” as well as other authors to suggest that between 4% and 18% of consecutive patients in outpatient settings suffer an iatrogenic event leading to:
- 116 million extra physician visits
- 77 million extra prescriptions filled
- 17 million emergency department visits
- 8 million hospitalizations
- 3 million long-term admissions
- 199,000 additional deaths
- $77 billion in extra costs.21
While some 12,000 deaths occur each year from unnecessary surgeries, results from the few studies that have measured unnecessary surgery directly indicate that for some highly controversial operations, the proportion of unwarranted surgeries could be as high as 30%.81
Medical Errors: A Global Issue
A five-country survey published in the Journal of Health Affairs found that 18-28% of people who were recently ill had suffered from a medical or drug error in the previous two years. The study surveyed 750 recently ill adults. The breakdown by country showed the percentages of those suffering a medical or drug error were 18% in Britain, 23% in Australia and in New Zealand, 25% in Canada, and 28% in the US.115
The Institute of Medicine recently found that the 41 million Americans with no health insurance have consistently worse clinical outcomes than those who are insured, and are at increased risk for dying prematurely.116
When doctors bill for services they do not render, advise unnecessary tests, or screen everyone for a rare condition, they are committing insurance fraud. The US GAO estimated that $12 billion was lost to fraudulent or unnecessary claims in 1998, and reclaimed $480 million in judgments in that year. In 2001, the federal government won or negotiated more than $1.7 billion in judgments, settlements, and administrative impositions in health care fraud cases and proceedings.117
Warehousing Our Elders
One way to measure the moral and ethical fiber of a society is by how it treats its weakest and most vulnerable members. In some cultures, elderly people live out their lives in extended family settings that enable them to continue participating in family and community affairs. American nursing homes, where millions of our elders go to live out their final days, represent the pinnacle of social isolation and medical abuse.
The report found:
- In America, approximately 1.6 million elderly are confined to nursing homes. By 2050, that number could be 6.6 million.18,118
- Twenty percent of all deaths from all causes occur in nursing homes.119
- Hip fractures are the single greatest reason for nursing home admissions.120
- Nursing homes represent a reservoir for drug-resistant organisms due to overuse of antibiotics.16
- Presenting a report he sponsored entitled “Abuse of Residents Is a Major Problem in US Nursing Homes” on July 30, 2001, Rep. Henry Waxman (D-CA) noted that “as a society we will be judged by how we treat the elderly.” The report found one third of the nation’s approximately 17,000 nursing homes were cited for an abuse violation in a two-year period from January 1999 to January 2001.118 According to Waxman, “the people who cared for us deserve better.” The report suggests that this known abuse represents only the “tip of the iceberg” and that much more abuse occurs that we are not aware of or ignore.118
- Over 30% of US nursing homes were cited for abuses, totaling more than 9,000 violations.
- Ten percent of nursing homes had violations that caused actual physical harm to residents or worse.
- Over 40% (3,800) of the abuse violations followed the filing of a formal complaint, usually by concerned family members.
- Many verbal abuse violations were found, as were occasions of sexual abuse.
- Incidents of physical abuse causing numerous injuries, such as fractured femurs, hips, elbows, and wrists, also were found.
Dangerously understaffed nursing homes lead to neglect, abuse, overuse of medications, and physical restraints. In 1990, Congress mandated an exhaustive study of nurse-to-patient ratios in nursing homes. The study was finally begun in 1998 and took four years to complete.121 A spokesperson for the National Citizens’ Coalition for Nursing Home Reform commented on the study: “They compiled two reports of three volumes, each thoroughly documenting the number of hours of care residents must receive from nurses and nursing assistants to avoid painful, even dangerous, conditions such as bedsores and infections. Yet it took the Department of Health and Human Services and Secretary Tommy Thompson only four months to dismiss the report as ‘insufficient.’”122 Although preventable with proper nursing care, bedsores occur three times more commonly in nursing homes than in acute care or veterans hospitals.123
Because many nursing home patients suffer from chronic debilitating conditions, their assumed cause of death often is unquestioned by physicians. Some studies show that as many as 50% of deaths due to restraints, falls, suicide, homicide, and choking in nursing homes may be covered up.124,125 It is possible that many nursing home deaths are instead attributed to heart disease. In fact, researchers have found that heart disease may be over-represented in the general population as a cause of death on death certificates by 8-24%. In the elderly, the over-reporting of heart disease as a cause of death is as much as twofold.126
That very few statistics exist concerning malnutrition in acute care hospitals and nursing homes demonstrates the lack of concern in this area. While a survey of the literature turns up few US studies, one revealing US study evaluated the nutritional status of 837 patients in a 100-bed subacute care hospital over a 14-month period. The study found only 8% of the patients were well nourished, while 29% were malnourished and 63% were at risk of malnutrition. As a result, 25% of the malnourished patients required readmission to an acute care hospital, compared to 11% of the well-nourished patients. The authors concluded that malnutrition reached epidemic proportions in patients admitted to this subacute care facility.127
Many studies conclude that physical restraints are an underreported and preventable cause of death. Studies show that compared to no restraints, the use of restraints carries a higher mortality rate and economic burden.128-130 Studies have found that physical restraints, including bedrails, are the cause of at least 1 in every 1,000 nursing-home deaths.131-133
Deaths caused by malnutrition, dehydration, and physical restraints, however, are rarely recorded on death certificates. Several studies reveal that nearly half of the listed causes of death on death certificates for elderly people with chronic or multi-system disease are inaccurate.134 Although one in five people dies in nursing homes, an autopsy is performed in less than 1% of these deaths.135