THE FIRST
IATROGENIC STUDY
Dr. Lucian L. Leape opened medicine's Pandora's box
in his 1994 paper, “Error in Medicine,” which appeared
in the Journal of the American Medical Association
(JAMA).(16)
He found that Schimmel reported in 1964 that 20% of
hospital patients suffered iatrogenic injury, with a 20%
fatality rate. In 1981 Steel reported that 36% of
hospitalized patients experienced iatrogenesis with a
25% fatality rate, and adverse drug reactions were
involved in 50% of the injuries. In 1991, Bedell
reported that 64% of acute heart attacks in one hospital
were preventable and were mostly due to adverse drug
reactions.
Leape focused on the “Harvard Medical Practice Study”
published in 1991,
(16a) which found a 4% iatrogenic injury rate for
patients, with a 14% fatality rate, in 1984 in New York
State. From the 98,609 patients injured and the 14%
fatality rate, he estimated that in the entire U.S.
180,000 people die each year partly as a result of
iatrogenic injury.
Why Leape chose to use the much lower figure of 4%
injury for his analysis remains in question. Using
instead the average of the rates found in the three
studies he cites (36%,
20%, and 4%) would have produced a 20% medical
error rate. The number of iatrogenic deaths using an
average rate of injury and his 14% fatality rate would
be 1,189,576.
Leape acknowledged that the literature on medical
errors is sparse and represents only the tip of the
iceberg, noting that when errors are specifically sought
out, reported rates are “distressingly high.” He cited
several autopsy studies with rates as high as 35-40% of
missed diagnoses causing death. He also noted that an
intensive care unit reported an average of 1.7 errors
per day per patient, and 29% of those errors were
potentially serious or fatal.
Leape calculated the error rate in the intensive care
unit study. First, he found that each patient had an
average of 178 “activities” (staff/procedure/medical
interactions) a day, of which 1.7 were errors, which
means a 1% failure rate. This may not seem like much,
but Leape cited industry standards showing that in
aviation, a 0.1% failure rate would mean two unsafe
plane landings per day at Chicago's O'Hare International
Airport; in the US Postal Service, a 0.1% failure rate
would mean 16,000 pieces of lost mail every hour; and in
the banking industry, a 0.1% failure rate would mean
32,000 bank checks deducted from the wrong bank account.
In trying to determine why there are so many medical
errors, Leape acknowledged the lack of reporting of
medical errors. Medical errors occur in thousands of
different locations and are perceived as isolated and
unusual events. But the most important reason that the
problem of medical errors is unrecognized and growing,
according to Leape, is that doctors and nurses are
unequipped to deal with human error because of the
culture of medical training and practice. Doctors are
taught that mistakes are unacceptable. Medical mistakes
are therefore viewed as a failure of character and any
error equals negligence. No one is taught what to do
when medical errors do occur. Leape cites McIntyre and
Popper, who said the “infallibility model” of medicine
leads to intellectual dishonesty with a need to cover up
mistakes rather than admit them. There are no Grand
Rounds on medical errors, no sharing of failures among
doctors, and no one to support them emotionally when
their error harms a patient.
Leape hoped his paper would encourage medical
practitioners “to fundamentally change the way they
think about errors and why they occur.” It has been
almost a decade since this groundbreaking work, but the
mistakes continue to soar.
In 1995, a JAMA report noted, "Over a
million patients are injured in US hospitals each year,
and approximately 280,000 die annually as a result of
these injuries. Therefore, the iatrogenic death rate
dwarfs the annual automobile accident mortality rate of
45,000 and accounts for more deaths than all other
accidents combined."(23)
At a 1997 press conference, Leape released a
nationwide poll on patient iatrogenesis conducted by the
National Patient Safety Foundation (NPSF), which is
sponsored by the American Medical Association
(AMA). Leape is
a founding member of NPSF. The survey found that more
than 100 million Americans have been affected directly
or indirectly by a medical mistake. Forty-two percent
were affected directly and 84% personally knew of
someone who had experienced a medical mistake.(14)
At this press conference, Leape updated his 1994
statistics, noting that as of 1997, medical errors in
inpatient hospital settings nationwide could be as high
as 3 million and could cost as much as $200 billion .
Leape used a 14% fatality rate to determine a medical
error death rate of 180,000 in 1994.(16)
In 1997, using Leape's base number of 3 million errors,
the annual death rate could be as high as 420,000 for
hospital inpatients alone.
ONLY A FRACTION OF MEDICAL ERRORS ARE
REPORTED
In 1994, Leape said he was well aware that medical
errors were not being reported.(16)
A study conducted in two obstetrical units in the UK
found that only about one-quarter of adverse incidents
were ever reported, to protect staff, preserve
reputations, or for fear of reprisals, including
lawsuits.(24).
An analysis by Wald and Shojania found that only 1.5% of
all adverse events result in an incident report, and
only 6% of adverse drug events are identified properly.
The authors learned that the American College of
Surgeons estimates that surgical incident reports
routinely capture only 5-30% of adverse events. In one
study, only 20% of surgical complications resulted in
discussion at morbidity and mortality rounds.(25)
From these studies, it appears that all the statistics
gathered on medical errors may substantially
underestimate the number of adverse drug and medical
therapy incidents. They also suggest that our statistics
concerning mortality resulting from medical errors may
be in fact be conservative figures.
An article in Psychiatric Times (April 2000)
outlines the stakes involved in reporting medical
errors.(26) The
authors found that the public is fearful of suffering a
fatal medical error, and doctors are afraid they will be
sued if they report an error. This brings up the obvious
question: who is reporting medical errors? Usually it is
the patient or the patient's surviving family. If no one
notices the error, it is never reported. Janet Heinrich,
an associate director at the U.S. General Accounting
Office responsible for health financing and public
health issues, testified before a House subcommittee
hearing on medical errors that "the full magnitude of
their threat to the American public is unknown” and
"gathering valid and useful information about adverse
events is extremely difficult." She acknowledged that
the fear of being blamed, and the potential for legal
liability, played key roles in the underreporting of
errors. The Psychiatric Times noted that the
AMA strongly opposes mandatory reporting of medical
errors.(26) If
doctors are not reporting, what about nurses? A survey
of nurses found that they also fail to report medical
mistakes for fear of retaliation.(27)
Standard medical pharmacology texts admit that
relatively few doctors ever report adverse drug
reactions to the FDA.(28)
The reasons range from not knowing such a reporting
system exists to fear of being sued.(29)
Yet the public depends on this tremendously flawed
system of voluntary reporting by doctors to know whether
a drug or a medical intervention is harmful.
Pharmacology texts also will tell doctors how hard it
is to separate drug side effects from disease symptoms.
Treatment failure is most often attributed to the
disease and not the drug or doctor. Doctors are warned,
“Probably nowhere else in professional life are mistakes
so easily hidden, even from ourselves.”(30)
It may be hard to accept, but it is not difficult to
understand why only 1 in 20 side effects is reported to
either hospital administrators or the FDA.(31,
31a)
If hospitals admitted to the actual number of errors
for which they are responsible, which is about 20 times
what is reported, they would come under intense
scrutiny.(32)
Jerry Phillips, associate director of the FDA's Office
of Post Marketing Drug Risk Assessment, confirms this
number. “In the broader area of adverse drug reaction
data, the 250,000 reports received annually probably
represent only 5% of the actual reactions that occur.”(33)
Dr. Jay Cohen, who has extensively researched adverse
drug reactions, notes that because only 5% of adverse
drug reactions are reported, there are in fact 5 million
medication reactions each year.(34)
A 2003 survey is all the more distressing because
there seems to be no improvement in error reporting,
even with all the attention given to this topic. Dr.
Dorothea Wild surveyed medical residents at a community
hospital in Connecticut and found that only half were
aware that the hospital had a medical error-reporting
system, and that the vast majority did not use it at
all. Dr. Wild says this does not bode well for the
future. If doctors don't learn error reporting in their
training, they will never use it. Wild adds that error
reporting is the first step in locating the gaps in the
medical system and fixing them. Not even that first step
has been taken to date.(35)
PUBLIC SUGGESTIONS ON IATROGENESIS
In a telephone survey, 1,207 adults ranked the
effectiveness of the following measures in reducing
preventable medical errors that result in serious harm.(36)
(Following each measure is the percentage of respondents
who ranked the measure as “very effective.”)
- giving doctors more time to spend with patients
(78%)
- requiring hospitals to develop systems to avoid
medical errors (74%)
- better training of health professionals (73%)
- using only doctors specially trained in
intensive care medicine on intensive care units
(73%)
- requiring hospitals to report all serious
medical errors to a state agency (71%)
- increasing the number of hospital nurses (69%)
- reducing the work hours of doctors in training
to avoid fatigue (66%)
- encouraging hospitals to voluntarily report
serious medical errors to a state agency (62%).
DRUG IATROGENESIS
Prescription drugs constitute the major treatment
modality of scientific medicine. With the discovery of
the “germ theory,” medical scientists convinced the
public that infectious organisms were the cause of
illness. Finding the “cure” for these infections proved
much harder than anyone imagined. From the beginning,
chemical drugs promised much more than they delivered.
But far beyond not working, the drugs also caused
incalculable side effects. The drugs themselves, even
when properly prescribed, have side effects that can be
fatal, as Lazarou's study(1)
showed. But human error can make the situation even
worse.
Medication Errors
A survey of a 1992 national pharmacy database found a
total of 429,827 medication errors from 1,081 hospitals.
Medication errors occurred in 5.22% of patients admitted
to these hospitals each year. The authors concluded that
at least 90,895 patients annually were harmed by
medication errors in the US as a whole.(37)
A 2002 study shows that 20% of hospital medications
for patients had dosage errors. Nearly 40% of these
errors were considered potentially harmful to the
patient. In a typical 300-patient hospital, the number
of errors per day was 40.(38)
Problems involving patients' medications were even
higher the following year. The error rate intercepted by
pharmacists in this study was 24%, making the potential
minimum number of patients harmed by prescription drugs
417,908.(39)
Recent Adverse
Drug Reactions
More-recent studies on adverse drug reactions show
that the figures from 1994 published in Lazarou's 1998
JAMA article may be increasing. A 2003 study
followed 400 patients after discharge from a tertiary
care hospital setting (requiring highly specialized
skills, technology, or support services). Seventy-six
patients (19%) had adverse events. Adverse drug events
were the most common, at 66% of all events. The next
most common event was procedure-related injuries, at
17%.(40)
In a New England Journal of Medicine study,
an alarming one in four patients suffered observable
side effects from the more than 3.34 billion
prescription drugs filled in 2002.(41)
One of the doctors who produced the study was
interviewed by Reuters and commented, "With these
10-minute appointments, it's hard for the doctor to get
into whether the symptoms are bothering the patients."(42)
William Tierney, who editorialized on the New
England Journal study, said “… given the increasing
number of powerful drugs available to care for the aging
population, the problem will only get worse.” The drugs
with the worst record of side effects were selective
serotonin reuptake inhibitors ( SSRIs), nonsteroidal
anti-inflammatory drugs (NSAIDs), and calcium-channel
blockers. Reuters also reported that prior research has
suggested that nearly 5% of hospital admissions (over 1
million per year) are the result of drug side effects.
But most of the cases are not documented as such. The
study found that one of the reasons for this failure is
that in nearly two-thirds of the cases, doctors could
not diagnose drug side effects or the side effects
persisted because the doctor failed to heed the warning
signs.
Medicating Our
Feelings
Patients seeking a more joyful existence and relief
from worry, stress, and anxiety often fall victim to the
messages endlessly displayed on TV and billboards.
Often, instead of gaining relief, they fall victim to
the myriad iatrogenic side effects of antidepressant
medication.
Moreover, a whole generation of antidepressant users
has been created from young people growing up on
Ritalin. Medicating youth and modifying their emotions
must have some impact on how they learn to deal with
their feelings. They learn to equate coping with drugs
rather than with their inner resources. As adults, these
medicated youth reach for alcohol, drugs, or even street
drugs to cope. According to JAMA , “Ritalin
acts much like cocaine.”(43)
Today's marketing of mood-modifying drugs such as Prozac
and Zoloft ® makes them not only socially acceptable but
almost a necessity in today's stressful world.
Television Diagnosis
To reach the widest audience possible, drug companies
are no longer just targeting medical doctors with their
marketing of antidepressants. By 1995, drug companies
had tripled the amount of money allotted to direct
advertising of prescription drugs to consumers. The
majority of this money is spent on seductive television
ads. From 1996 to 2000, spending rose from $791 million
to nearly $2.5 billion.(44)
This $2.5 billion represents only 15% of the total
pharmaceutical advertising budget. While the drug
companies maintain that direct-to-consumer advertising
is educational, Dr. Sidney M. Wolfe of the Public
Citizen Health Research Group in Washington, DC, argues
that the public often is misinformed about these ads.(45)
People want what they see on television and are told to
go to their doctors for a prescription. Doctors in
private practice either acquiesce to their patients'
demands for these drugs or spend valuable time trying to
talk patients out of unnecessary drugs. Dr. Wolfe
remarks that one important study found that people
mistakenly believe that the “FDA reviews all ads before
they are released and allows only the safest and most
effective drugs to be promoted directly to the public.”(46)
How Do We Know
Drugs Are Safe?
Another aspect of scientific medicine that the public
takes for granted is the testing of new drugs. Drugs
generally are tested on individuals who are fairly
healthy and not on other medications that could
interfere with findings. But when these new drugs are
declared “safe” and enter the drug prescription books,
they are naturally going to be used by people who are on
a variety of other medications and have a lot of other
health problems. Then a new phase of drug testing called
“post-approval” comes into play, which is the
documentation of side effects once drugs hit the market.
In one very telling report, the federal government's
General Accounting Office "found that of the 198 drugs
approved by the FDA between 1976 and 1985... 102 (or
51.5%) had serious post-approval risks... the serious
post-approval risks (included) heart failure, myocardial
infarction, anaphylaxis, respiratory depression and
arrest, seizures, kidney and liver failure, severe blood
disorders, birth defects and fetal toxicity, and
blindness."(47)
NBC Television's investigative show “Dateline”
wondered if your doctor is moonlighting as a drug
company representative. After a yearlong investigation,
NBC reported that because doctors can legally prescribe
any drug to any patient for any condition, drug
companies heavily promote "off label" and frequently
inappropriate and untested uses of these medications,
even though these drugs are approved only for the
specific indications for which they have been tested.(48)
The leading causes of adverse drug reactions are
antibiotics (17%),
cardiovascular drugs
(17%), chemotherapy
(15%), and
analgesics and anti-inflammatory agents (15%).(49)
Specific Drug Iatrogenesis: Antibiotics
According to William Agger, MD, director of
microbiology and chief of infectious disease at
Gundersen Lutheran Medical Center in La Crosse, WI, 30
million pounds of antibiotics are used in America each
year.(50) Of
this amount, 25 million pounds are used in animal
husbandry, and 23 million pounds are used to try to
prevent disease and the stress of shipping, as well as
to promote growth. Only 2 million pounds are given for
specific animal infections. Dr. Agger reminds us that
low concentrations of antibiotics are measurable in many
of our foods and in various waterways around the world,
much of it seeping in from animal farms.
Agger contends that overuse of antibiotics results in
food-borne infections resistant to antibiotics.
Salmonella is found in 20% of ground meat, but the
constant exposure of cattle to antibiotics has made 84%
of salmonella resistant to at least one anti-salmonella
antibiotic. Diseased animal food accounts for 80% of
salmonellosis in humans, or 1.4 million cases per year.
The conventional approach to countering this epidemic is
to radiate food to try to kill all organisms while
continuing to use the antibiotics that created the
problem in the first place. Approximately 20% of
chickens are contaminated with Campylobacter jejuni,
an organism that causes 2.4 million cases of illness
annually. Fifty-four percent of these organisms are
resistant to at least one anti-campylobacter
antimicrobial agent.
Denmark banned growth-promoting antibiotics beginning
in 1999, which cut their use by more than half within a
year, from 453,200 to 195,800 pounds. A report from
Scandinavia found that removing antibiotic growth
promoters had no or minimal effect on food production
costs. Agger warns that the current crowded, unsanitary
methods of animal farming in the US support constant
stress and infection, and are geared toward high
antibiotic use.
In the US, over 3 million pounds of antibiotics are
used every year on humans. With a population of 284
million Americans, this amount is enough to give every
man, woman, and child 10 teaspoons of pure antibiotics
per year. Agger says that exposure to a steady stream of
antibiotics has altered pathogens such as
Streptococcus pneumoniae, Staplococcus aureus,
and entercocci, to name a few.
Almost half of patients with upper respiratory tract
infections in the U.S. still receive antibiotics from
their doctor.(51)
According to the CDC, 90% of upper respiratory
infections are viral and should not be treated with
antibiotics. In Germany, the prevalence of systemic
antibiotic use in children aged 0-6 years was 42.9%.(52)
Data obtained from nine US health insurers on
antibiotic use in 25,000 children from 1996 to 2000
found that rates of antibiotic use decreased. Antibiotic
use in children aged three months to under 3 years
decreased 24%, from 2.46 to 1.89 antibiotic
prescriptions per patient per year. For children aged 3
to under 6 years, there was a 25% reduction from 1.47 to
1.09 antibiotic prescriptions per patient per year. And
for children aged 6 to under 18 years, there was a 16%
reduction from 0.85 to 0.69 antibiotic prescriptions per
patient per year.(53)
Despite these reductions, the data indicate that on
average every child in America receives 1.22 antibiotic
prescriptions annually.
Group A beta-hemolytic streptococci is the only
common cause of sore throat that requires antibiotics,
with penicillin and erythromycin the only recommended
treatment. Ninety percent of sore-throat cases, however,
are viral. Antibiotics were used in 73% of the estimated
6.7 million adult annual visits for sore throat in the
US between 1989 and 1999. Furthermore, patients treated
with antibiotics were prescribed non-recommended
broad-spectrum antibiotics in 68% of visits. This period
saw a significant increase in the use of newer, more
expensive broad-spectrum antibiotics and a decrease in
use of the recommended antibiotics penicillin and
erythromycin.(54)
Antibiotics being prescribed in 73% of sore-throat
cases instead of the recommended 10% resulted in a total
of 4.2 million unnecessary antibiotic prescriptions from
1989 to 1999.
The Problem with
Antibiotics
In September 2003, the CDC re-launched a program
started in 1995 called “Get Smart: Know When Antibiotics
Work.”(55) This
$1.6 million campaign is designed to educate patients
about the overuse and inappropriate use of antibiotics.
Most people involved with alternative medicine have
known about the dangers of antibiotic overuse for
decades. Finally the government is focusing on the
problem, yet it is spending only a miniscule amount of
money on an iatrogenic epidemic that is costing billions
of dollars and thousands of lives. The CDC warns that
90% of upper respiratory infections, including
children's ear infections, are viral and that
antibiotics do not treat viral infection. More than 40%
of about 50 million prescriptions for antibiotics
written each year in physicians' offices are
inappropriate.(2)
Using antibiotics when not needed can lead to the
development of deadly strains of bacteria that are
resistant to drugs and cause more than 88,000 deaths due
to hospital-acquired infections.(9)
The CDC, however, seems to be blaming patients for
misusing antibiotics even though they are available only
by prescription from physicians. According to Dr.
Richard Besser, head of “Get Smart”: "Programs that have
just targeted physicians have not worked.
Direct-to-consumer advertising of drugs is to blame in
some cases.” Besser says the program “teaches patients
and the general public that antibiotics are precious
resources that must be used correctly if we want to have
them around when we need them. Hopefully, as a result of
this campaign, patients will feel more comfortable
asking their doctors for the best care for their
illnesses, rather than asking for antibiotics."(56)
Cesarean Section
In 1983, 809,000 cesarean sections (21% of
live births) were performed in the US, making it
the nation's most common obstetric-gynecologic
(OB/GYN) surgical procedure. The second most
common OB/GYN operation was hysterectomy
(673,000), followed by diagnostic dilation and
curettage of the uterus (632,000). In 1983, OB/GYN
procedures represented 23% of all surgery
completed in the US.(104)
In 2001, cesarean section is still the most
common OB/GYN surgical procedure. Approximately
4 million births occur annually, with 24%
(960,000) delivered by cesarean section. In the
Netherlands, only 8% of births are delivered by
cesarean section. This suggests 640,000
unnecessary cesarean sections—entailing three to
four times higher mortality and 20 times greater
morbidity than vaginal delivery(105)—are
performed annually in the US.
The US cesarean rate rose from just 4.5% in
1965 to 24.1% in 1986. Sakala contends that an
“uncontrolled pandemic of medically unnecessary
cesarean births is occurring.”(106)
VanHam reported a cesarean section postpartum
hemorrhage rate of 7%, a hematoma formation rate
of 3.5%, a urinary tract infection rate of 3%,
and a combined postoperative morbidity rate of
35.7% in a high-risk population undergoing
cesarean section.(107)
NEVER ENOUGH STUDIES
Scientists claimed there were never enough
studies revealing the dangers of DDT and other
dangerous pesticides to ban them. They also used
this argument for tobacco, claiming that more
studies were needed before they could be certain
that tobacco really caused lung cancer. Even the
American Medical Association (AMA) was complicit
in suppressing the results of tobacco research.
In 1964, when the Surgeon General's report
condemned smoking, the AMA refused to endorse
it, claiming a need for more research. What they
really wanted was more money, which they
received from a consortium of tobacco companies
that paid the AMA $18 million over the next nine
years during which the AMA said nothing about
the dangers of smoking.(108)
The Journal of the American Medical
Association (JAMA), "after careful
consideration of the extent to which cigarettes
were used by physicians in practice," began
accepting tobacco advertisements and money in
1933. State journals such as the New York
State Journal of Medicine also began to run
advertisements for Chesterfield cigarettes that
claimed cigarettes are "Just as pure as the
water you drink… and practically untouched by
human hands." In 1948, JAMA argued
"more can be said in behalf of smoking as a form
of escape from tension than against it… there
does not seem to be any preponderance of
evidence that would indicate the abolition of
the use of tobacco as a substance contrary to
the public health."(109)
Today, scientists continue to use the excuse
that more studies are needed before they will
support restricting the inordinate use of drugs.
ADVERSE DRUG
REACTIONS
The Lazarou study(1)
analyzed records for prescribed medications for
33 million US hospital admissions in 1994. It
discovered 2.2 million serious injuries due to
prescribed drugs; 2.1% of inpatients experienced
a serious adverse drug reaction, 4.7% of all
hospital admissions were due to a serious
adverse drug reaction, and fatal adverse drug
reactions occurred in 0.19% of inpatients and
0.13% of admissions. The authors estimated that
106,000 deaths occur annually due to adverse
drug reactions.
Using a cost analysis from a 2000 study in
which the increase in hospitalization costs per
patient suffering an adverse drug reaction was
$5,483, costs for the Lazarou study's 2.2
million patients with serious drug reactions
amounted to $12 billion.(1,49)
Serious adverse drug reactions commonly
emerge after FDA approval of the drugs involved.
The safety of new agents cannot be known with
certainty until a drug has been on the market
for many years.(110)
BEDSORES
Over one million people develop bedsores in
U.S. hospitals every year. It's a tremendous
burden to patients and family, and a $55 billion
dollar healthcare burden.
(7)
Bedsores are preventable with proper nursing
care. It is true that 50% of those affected are
in a vulnerable age group of over 70. In the
elderly bedsores carry a fourfold increase in
the rate of death. The mortality rate in
hospitals for patients with bedsores is between
23% and 37%.
(8) Even if we just take the 50% of
people over 70 with bedsores and the lowest
mortality at 23%, that gives us a death rate due
to bedsores of 115,000. Critics will say that it
was the disease or advanced age that killed the
patient, not the bedsore, but our argument is
that an early death, by denying proper care,
deserves to be counted. It is only after
counting these unnecessary deaths that we can
then turn our attention to fixing the problem.
MALNUTRITION IN NURSING HOMES
The General Accounting Office
(GAO),
a special investigative branch of Congress,
cited 20% of the nation's 17,000 nursing homes
for violations between July 2000 and January
2002. Many violations involved serious physical
injury and death.(111)
A report from the Coalition for Nursing Home
Reform states that at least one-third of the
nation's 1.6 million nursing home residents may
suffer from malnutrition and dehydration, which
hastens their death. The report calls for
adequate nursing staff to help feed patients who
are not able to manage a food tray by
themselves.(11)
It is difficult to place a mortality rate on
malnutrition and dehydration. The Coalition
report states that malnourished residents,
compared with well-nourished hospitalized
nursing home residents, have a fivefold increase
in mortality when they are admitted to a
hospital. Multiplying the one-third of 1.6
million nursing home residents who are
malnourished by a mortality rate of 20%(8,14)
results in 108,800 premature deaths due to
malnutrition in nursing homes.
Nosocomial
Infections
The rate of nosocomial infections per 1,000
patient days rose from 7.2 in 1975 to 9.8 in
1995, a 36% jump in 20 years. Reports from more
than 270 US hospitals showed that the nosocomial
infection rate itself had remained stable over
the previous 20 years, with approximately five
to six hospital-acquired infections occurring
per 100 admissions, a rate of 5-6%. Due to
progressively shorter inpatient stays and the
increasing number of admissions, however, the
number of infections increased. It is estimated
that in 1995, nosocomial infections cost $4.5
billion and contributed to more than 88,000
deaths, or one death every 6 minutes.(9)
The 2003 incidence of nosocomial mortality is
quite probably higher than in 1995 because of
the tremendous increase in antibiotic-resistant
organisms. Morbidity and Mortality Report found
that nosocomial infections cost $5 billion
annually in 1999,(10)
representing a $0.5 billion increase in just
four years. At this rate of increase, the
current cost of nosocomial infections would be
around $5.5 billion.
Outpatient
Iatrogenesis
In a 2000 JAMA article, Dr. Barbara
Starfield presents well-documented facts that
are both shocking and unassailable.(12)
The U.S. 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 warns 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 Westernized
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(112)
Unnecessary
Surgeries
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%.(74)
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.(113)
HEALTH INSURANCE
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
(114).
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 dollars 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.(115)
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 lives 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.
- In America, approximately 1.6 million
elderly are confined to nursing homes. By
2050, that number could be 6.6 million.(11,116)
- Twenty percent of all deaths from all
causes occur in nursing homes.(117)
- Hip fractures are the single greatest
reason for nursing home admissions.(118)
- Nursing homes represent a reservoir for
drug-resistant organisms due to overuse of
antibiotics.(119)
Presenting a report he sponsored entitled
"Abuse of Residents is a Major Problem in U.S.
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.(116)
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
aware of or ignore.(116a)
The report found:
- Over 30% of US nursing homes were cited
for abuses, totaling more than 9,000
violations.
- 10% 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.
- Occasions of sexual abuse.
- Incidents of physical abuse causing
numerous injuries such as fractured femur,
hip, elbow, wrist, and other injuries.
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.(120)
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.'”(121)
Although preventable with proper nursing care,
bedsores occur three times more commonly in
nursing homes than in acute care or veterans
hospitals.(122).
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.(123,124)
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 overreporting of heart
disease as a cause of death is as much as
twofold.(125)
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.(126)
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.(127-129)
Studies have found that physical restraints,
including bedrails, are the cause of at least 1
in every 1,000 nursing-home deaths.(130-132)
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.(133)
Even though 1 in 5 people die in nursing homes,
an autopsy is performed in less than 1% of these
deaths.(134).
Overmedicating
Seniors
Dr. Robert Epstein, chief medical officer of
Medco Health Solutions Inc. (a unit of Merck &
Co.), conducted a study in 2003 of drug trends
among the elderly.(135)
He found that seniors are going to multiple
physicians, getting multiple prescriptions, and
using multiple pharmacies. Medco oversees
drug-benefit plans for more than 60 million
Americans, including 6.3 million seniors who
received more than 160 million prescriptions.
According to the study, the average senior
receives 25 prescriptions each year. Among those
6.3 million seniors, a total of 7.9 million
medication alerts were triggered: less than
one-half that number, 3.4 million, were detected
in 1999. About 2.2 million of those alerts
indicated excessive dosages unsuitable for
seniors, and about 2.4 million alerts indicated
clinically inappropriate drugs for the elderly.
Reuters interviewed Kasey Thompson, director of
the Center on Patient Safety at the American
Society of Health System Pharmacists, who noted:
“There are serious and systemic problems with
poor continuity of care in the United States .”
He says this study represents only “the tip of
the iceberg” of a national problem.
According to Drug Benefit Trends ,
the average number of prescriptions dispensed
per non-Medicare HMO member per year rose 5.6%
from 1999 to 2000, - from 7.1 to 7.5
prescriptions. The average number dispensed for
Medicare members increased 5.5%, from 18.1 to
19.1 prescriptions.(136)
The total number of prescriptions written in the
US in 2000 was 2.98 billion, or 10.4
prescriptions for every man, woman, and child.(137)
In a study of 818 residents of residential
care facilities for the elderly, 94% were
receiving at least one medication at the time of
the interview. The average intake of medications
was five per resident; the authors noted that
many of these drugs were given without a
documented diagnosis justifying their use.(138)
Seniors and groups like the American
Association for Retired Persons
(AARP)
are demanding that prescription drug coverage be
a basic right.(139)
They have accepted allopathic medicine's
overriding assumption that aging and dying in
America must be accompanied by drugs in nursing
homes and eventual hospitalization. Seniors are
given the choice of either high-cost patented
drugs or low-cost generic drugs. Drug companies
attempt to keep the most expensive drugs on the
shelves and suppress access to generic drugs,
despite facing stiff fines of hundreds of
millions of dollars levied by the federal
government.(140,141)
In 2001, some of the world's largest drug
companies were fined a record $871 million for
conspiring to increase the price of vitamins.(142)
Current AARP recommendations for diet and
nutrition assume that seniors are getting all
the nutrition they need in an average diet. At
most, AARP suggests adding extra calcium and a
multivitamin and mineral supplement.(143)
Ironically, studies also indicate underuse of
proper pain medication for patients who need it.
One study evaluated pain management in a group
of 13,625 cancer patients, aged 65 and over,
living in nursing homes. While almost 30% of the
patients reported pain, more than 25% received
no pain relief medication, 16% received a mild
analgesic drug, 32% received a moderate
analgesic drug, and 26% received adequate
pain-relieving morphine. The authors concluded
that older patients and minority patients were
more likely to have their pain untreated.(144)
WHAT
REMAINS TO BE UNCOVERED
Our ongoing research will continue to
quantify the morbidity, mortality, and financial
loss due to:
- X-ray exposures (mammography,
fluoroscopy, CT scans).
- Overuse of antibiotics for all
conditions.
- Carcinogenic drugs (hormone replacement
therapy,* immunosuppressive and prescription
drugs).
- Cancer chemotherapy(70)
- Surgery and unnecessary surgery (cesarean
section, radical mastectomy, preventive
mastectomy, radical hysterectomy,
prostatectomy, cholecystectomies, cosmetic
surgery, arthroscopy, etc.).
- Discredited medical procedures and
therapies.
- Unproven medical therapies.
- Outpatient surgery.
- Doctors themselves.
* Part of our ongoing research will be to
quantify the mortality and morbidity caused by
hormone replacement therapy (HRT) since the
1940s. In December 2000, a government scientific
advisory panel recommended that synthetic
estrogen be added to the nation's list of
cancer-causing agents. HRT, either synthetic
estrogen alone or combined with synthetic
progesterone, is used by an estimated 13.5 to 16
million women in the US.(145)
The aborted Women's Health Initiative Study (WHI)
of 2002 showed that women taking synthetic
estrogen combined with synthetic progesterone
have a higher incidence of ovarian cancer,
breast cancer, stroke, and heart disease, with
little evidence of osteoporosis reduction or
dementia prevention. WHI researchers, who
usually never make recommendations except to
suggest more studies, advised doctors to be very
cautious about prescribing HRT to their
patients.(100,146-150)
Results of the “Million Women Study” on HRT
and breast cancer in the UK were published in
medical journal The Lancet in August
2003. According to lead author Prof. Valerie
Beral, director of the Cancer Research UK
Epidemiology Unit: "We estimate that over the
past decade, use of HRT by UK women aged 50-64
has resulted in an extra 20,000 breast cancers,
estrogen-progestagen (combination) therapy
accounting for 15,000 of these.”(151)
We were unable to find statistics on breast
cancer, stroke, uterine cancer, or heart disease
caused by HRT used by American women. Because
the US population is roughly six times that of
the UK, it is possible that 120,000 cases of
breast cancer have been caused by HRT in the
past decade. |
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