by David Cundiff, MD
To address the huge problem of errors by health professionals causing injuries and deaths to hospitalized patients, the U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius unveiled the Partnership for Patients initiative.
Secretary Sebelius referred to a recent study showing that adverse events in hospitalized patients, including those caused by human errors (i.e., preventable), occur about 10 times as frequently as previously thought—at least 49 adverse events per 100 hospital admissions including about 20 errors.
Plugging this error rate estimate into the U.S. Agency for Healthcare Research and Quality’s National and regional estimates on hospital use for 2008 (last available year), roughly 8 million patient injuries caused by errors occurred in 40 million hospitalizations. An unknown number of additional errors were not documented in the hospital records.
As a hospital-based practicing physician for 25 years, I can attest that hospitals are life-saving for many patients with major trauma, high-risk pregnancies, and many other conditions. However, hospitals are also dangerous places. To prevent adverse events and errors in hospitals, hospitalize fewer people.
The current hospital bed utilization rate per capita is about half that of 40 years ago. Consequently, the hospital error and injury rate is down. Reducing hospital bed utilization by half again would predictably reduce hospital-related adverse events and errors significantly while reducing overall health care costs by at least 10% (> $300 billion per year). Unfortunately, the Partnership for Patients program description makes no mention of reducing patient days in hospitals to improve care and decrease adverse events.
Why do patients spend unnecessary days in hospitals?
In the current business model of hospitals, physician “pay for performance” means filling as many beds as possible with insurance-reimbursable patients. While no hospital administrator wishes harm on patients, adverse events occurring to hospitalized patients increase hospital revenues. Consequently, more errors injuring patients is a side effect of maximizing profits in the hospital business.
The HHS patient safety plan targets nine common types of errors in hospitals. The tools highlighted to reduce these errors include checklists, public reporting, “evidence-based” guidelines, and financial incentives (“pay for performance”). Except for checklists, these tools are quite problematic. For a start, the public disclosure of 8 million errors occurring in hospitals per year is not advisable and administratively impossible. Additionally, according to a report recently issued by the Institute of Medicine (a branch of HHS), not all evidence-based guidelines are valid. Furthermore, the report discloses that the HHS has no mechanism to determine which guidelines are valid and which are not. Since financial incentives generally involve compliance with evidence-based guidelines, pay for performance bonuses won’t improve care if the guidelines are not valid. Indeed, compliance with invalid guidelines may harm patients. As I argued in a recent post in Care and Cost, HHS does not have and is not likely to develop an “easy trustworthiness guide” for all clinical practice guidelines suitable for using in conjunction with electronic medical records to coerce physicians to comply with HHS clinical care dictates.
For example, one of the nine hospitalization-related adverse events targeted by the Partnership for Patients program is venous thromboembolism (VTE: leg and lung vein clots) which occurs more commonly in patients with certain risk factors. The HHS refers to an “evidence-based” VTE guideline that recommends that physicians order anticoagulant drugs as prophylaxis against the development of VTE for most hospitalized patients. I challenged the validity of that guideline in four peer-reviewed medical journal publications (most recent here). HHS leaders will not rebut or affirm my data and conclusions.
We need to reduce preventable deaths and complications in hospitalized patients. However, forcing physicians to slavishly follow often flawed clinical treatment guidelines and capriciously exposing a relatively small subset of the millions of errors made by physicians and other health care professionals is not the solution. Instead, HHS should find strategies to address the underlying health care financing system dysfunction and associated medical culture rewarding excessive hospitalization that lead to unnecessary patient days in hospital and the associated errors and patient injuries.
According to the Agency for Healthcare Research and Quality (a branch of HHS), 10% of hospital days are medically unnecessary. But that is just the tip of the iceberg. I suggest two places to begin. Nearly one-third of Medicare spending goes for tests and treatments in the last six months of life for patients with advanced chronic illnesses (e.g., cancer and heart failure). Much of this “care” in hospital is burdensome for patients. Hospitalizations could best be avoided by earlier access to palliative care/hospice programs and by managing acute exacerbations of chronic medical problems with home hospital care as has been shown to be safe, effective, less expensive, and well received by patients.
Please email the Partnership for Patients program with your thoughts.
David Cundiff is an internal medicine physician.
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