Sunday, February 26, 2012

Friends of Science in Medicine: Hypocritical call to action

Update: 17-Jul-2012: There is now considerable blowback from the Medical Community towards Dwyer and his "little Friends". The MJA [Medical Journal of Australia, behind a paywall] of 16-Jul had multiple articles on this topic.

From a report on the Editorial and associated articles.

Professor Stephen Myers, SCU [Southern Cross University]:
“the real benefit of an appropriately mentored and approved university education is the exposure of students to the biomedical sciences, epidemiology and population health, differential diagnosis, safe
practice and critical appraisal."
Professor Paul Komesaroff, Monash University, on MacLennan's MJA in editorial in March-2012:
“exceed the boundaries of reasoned debate and risk compromising the values that FSM claims to support”.
Professor Komesaroff:
"while there was now an extensive evidence base in relation to complementary therapies, the concept of evidence-based medicine was highly contested and debated within Western medicine itself." 
"It is not appropriate for doctors or scientists with a particular view of medicine to impose those views on the whole community; rather, they should respect the rights of individuals to choose the approach to health care they feel is suitable for them." 
“It is important that those who seek to be friends of science do not inadvertently become its enemies. We call on the members of FSM to revise their tactics and instead support open, respectful dialogue in the great spirit and tradition of science itself”

In writing an inadvertently long piece on the Irrelevance of Marron and Dwyer's "Friends of Science in Medicine", I had to reflect on what what a convincing "short version" would be. Here's an attempt:
  • Dwyer, as a respected and long-serving medico, has to be aware of the estimated 18-35,000 preventable deaths in Australian Hospitals each and every year. [1995 QAHCS report, disputed.]
  • He must also be aware of the lack of good data on Adverse Events (AE) and Iatrogenic Injuries.
  • Similarly, the extra $2B/year estimated additional cost of treating AE's in hospitals.
  • He should also be aware of Dr Brent James reports (2001) from Intermountain Health, Utah, that only "3.5% (of patient injuries) resulted because of a human error" and from the APSF report on Iatrogenic Injuries (2001)  "The causes of iatrogenic injury appear to be systemic".
  • There is also a 2004 report on the effects and additional preventable deaths from overcrowding in Accident and Emergency. 
All of which could be used to suggest by Dwyer and friends:
Australian Medicine and Hospitals do very well in the face of insurmountable odds and lack of Political will and funding. [A justification used by AMA President Rosanna Capolingua in 2008, below.]
Only it isn't so...
Compare the complete lack of an Evidence Base for Patient Outcomes for Australians and any coherent, credible, co-ordinated plan to address this with the UK's Civil Aviation Authority's current Safety Plan
Secondly, Dr Brent James reported a 20% reduction in costs by reducing Patient Injuries through a "Do it Right, First Time" approach to Quality. This corresponds with the 2002 results from Ehsani, Jackson and Duckett. As Berwick suggests, organisational change is required to address systemic issues. Unless the system is changed, results won't change.
The CAA's Safety Plan [excerpted below] conspicuously shares a feature unknown in Australian Medical literature and seemingly in Hospital improvement plans: The Most Important Problems List.

The CAA has its "Significant Seven" and Dr James his "Bg Six List".
These seem unknown and unreported in Australian Hospitals and Health Department Plans and Operations.

Where this line of reasoning leads to:
After 50 years of large jet aircraft being used in Commercial Aviation, 'we' know exactly what has to be done to economically achieve good, reliable and safe Public Services, so why isn't this approach being advocated and adopted by Medicos and Hospitals?
From Dr. James, we also know that it is cheaper to fix systemic issues through a "Get it Right First Time" Quality approach, so after more than a decade of being known in Australia is this not being done?
How many "Adverse Events" are there in the Australian Hospital system? We don't know.
But the best evidence available is that they are not reducing. [below]
The most conservative estimates, "Sentinel Events", counts around 270 adverse events/year.
The QAHCS report estimated 18,000, the difference being direct, provable causality.
While the Australian Doctors Fund (ADF) would like us to use the American UTCOS report figure of 3.3 times less, of ~5,500 per year.

From Dr. James definitive work, the number of patient injuries is around 30 times the number of Adverse Events reported, reasonably 165,000 per year.

So why isn't Prof. Dwyer advocating and campaigning for the Medical Profession in Australia to adopt known, effective Evidence-Based Systems for itself preventing thousands of deaths, eliminating hundreds of thousands of injuries and reducing needless waste, rather than what appears to be a distracting side-show of "look at all those Bad Guys over there!".

This is the nub of his hypocrisy: Everyone else is doing it wrong, but we are beyond reproach.

From the UK CAA's Safety Plan 2010-2013:
The CAA ‘Significant Seven’ safety issues were identified following analyses of global fatal accidents and high-risk occurrences involving large UK commercial air transport (CAT) aeroplanes. 
This Plan has been developed by the CAA in partnership with industry because although the CAA has a safety oversight responsibility, industry has prime responsibility for managing their safety risk. 
We are taking a proactive approach to safety and our Plan is outcome focussed with great emphasis on safety performance. 
 We must deliver results that make a measurable difference, and ensure that we make the very best use of our available resources. 
‘Significant Seven’ Safety Issues (in priority order)
 1. Loss of Control
 2. Runway Excursion
 3. Controlled Flight into Terrain
 4. Runway Incursion
 5. Airborne Conflict
 6. Ground Handling
 7. Airborne and Post-Crash Fire 
Key Capabilities Required for the Total Aviation System
 * Integrated Safety Risk Management Process
 * Continuing Airworthiness
 * SMS [Safety Management Systems]
 * Just Culture
 * Human Factors
 * Performance-Based Oversight
 * Fatigue Risk Management Systems
 * Total System Threats

"The incidence and cost of adverse events in Victorian hospitals 2003–04", Ehsani, Jackson, Duckett. MJA 2006; 184: 551–555
During the designated timeframe, 979 834 admitted episodes were in the sample, of which 67 435 (6.88%) had at least one adverse event. 
Patients with adverse events stayed about 10 days longer and had over seven times the risk of in-hospital death than those without complications. 
After adjusting for age and comorbidity, the presence of an adverse event adds $6826 to the cost of each admitted episode. 
The total cost of adverse events in this dataset in 2003–04 was $460.311 million, representing 15.7% of the total expenditure on direct hospital costs, or an additional 18.6% of the total inpatient hospital budget.

Medical Errors Australia on "Needless Deaths":

quote from:

"The Quality in Australian Health Care Study", Wilson, Runciman, Gibberd, Harrison, Newby and Hamilton. MJA 1995; 163: 458-471

A review of the medical records of over 14,000 admissions to 28 hospitals in New South Wales and South Australia revealed that 16.6% of these admissions were associated with an “adverse event”, which resulted in disability or a longer hospital stay for the patient and was caused by health care management; 51% of the adverse events were considered preventable. In 77.1% the disability had resolved within 12 months, but in 13.7% the disability was permanent and in 4.9% the patient died.

Australia-wide estimates
The number of patients dying or incurring permanent disability each year in Australian hospitals as a result of AEs is estimated to be:
18 000 deaths (95% CI, 12 000–23 000);
17 000 (95% CI, 12 000–22 000) cases with permanent disability (> 50%); and
33 000 (95% CI, 27 000–37 000) cases with permanent disability (< 50%).
There are estimated to be 280 000 (95% CI, 260 000–310 000) AEs resulting in temporary disability.

Hospital deaths not decreasing: new study

Wednesday, 22 December 2004

The number of fatal accidents in South Australia's hospitals is not decreasing despite greater knowledge of how they occur, according to new research at the University of Adelaide.

The findings are contained in a thesis written by PhD graduate Dr Carol Grech in the University of Adelaide's Department of Public Health.

Dr Grech found that many solutions have been proposed over the years to reduce the incidence of fatal errors in South Australia's hospitals, to little effect.

"The Coroner regularly and repeatedly identifies the same factors underlying fatal adverse events," she says.

"Despite this knowledge, and the fact that many adverse events are predictable and preventable, there is little evidence that the incidence of medical fatalities is appreciably declining.

"If government and health bureaucrats are serious about preventing fatal adverse events, then significant attention needs to be given to implementing recommendations handed down by the Coroner."

"Consumers of health care services, as well as those who work in the health system, are deserving of a safer hospital system," Dr Grech says.

"Recommendations arising from impartial, transparent and objective inquiries into hospital-related fatalities have the potential to improve public health by ensuring a safer healthcare system," she says.

"This is conditional, of course, on intended recipients of such recommendations actively learning from the findings and translating this knowledge into policies that are embedded into clinical practice."

If this does not occur, Dr Grech says, the government should either amend the Coroner's Act or consider abolishing the office.

The aim of Dr Grech's research was to establish whether the Coroner's findings have contributed to quality improvement in hospitals.

Politics and publishing: the Quality in Australian Health Care Study

"In medical research, the real news is the evidence, not the public claim" [disputing the QAHCS]

MJA 1995; 163: 453-454

Reducing the Incidence of Adverse Events in Australian Hospitals: An Expert Panel Evaluation of Some Proposals, 2007, Professor Jeff Richardson, Foundation Director, Centre for Health Economics, Monash University

The aim of this paper is to demonstrate a method for identifying policy options for reducing adverse events in Australia’s hospitals, which could have been adopted, but was not adopted, in the wake of the landmark 1995 ‘Quality in Australian Health Care’ study, and to indicate the lapse time before these measures could be expected to have a major effect.

... expertise, position and publications in the area of adverse events and quality assurance. Forty-one options were identified with an average lapse time of 3.5 years. Hospital regulation had the least delay (2.4) years, and out of hospital information the greatest (6.4 years).

Following identification of the magnitude of the problem of adverse events in the ‘Quality in Australian Health Care’ study a more rapid response was possible than occurred. Viable options for reducing adverse events remain.

[The Australian Doctors Fund is making a case for using the American UTCOS report of 3.3 times fewer 'adverse events' than QAHCS.]

Quality in Australian Health Care Study: Examined OR Exposed?

Stephen Milgate
Executive Director
Australian Doctors' Fund
25 February 2003

"In medical research, the real news is the evidence, not the public claim."

References and quotes:
The Medical Journal of Australia, Vol 163, 6 November 1995
"The idea that every time there's an injury we write a rule, that just makes the world so hopelessly complex, it would probably increase injury rates." 
Minimising Harm to Patients in Hospital. Broadcast Monday 1 October 2001. Radio National. With Dr Brent James, Executive Director of Intermountain Health Care in Salt Lake City, Utah. 
"Most adverse events referred to are systems problems and not the failings of an individual clinician."

A year after the QAHCS was released a virtually identical US study, Utah-Colorado Study (UTCOS) with dramatically different results for the same base year, was published by the very reputable Harvard School of Public Health.

This forced the Federal Government to commission the Harvard School of Public Health to investigate why QAHCS and UTCOS had produced such a wide discrepancy in results using identical methodology.

In response, the Harvard School of Public Health and others producedtwo papers, A comparison of iatrogenic injury studies in Australia and the United States 1: Context, methods, casemix, population, patient and hospital characteristics and A comparison of iatrogenic injury studies in Australia and America 11: Reviewer behaviour and quality of care.

These studies were embargoed and not published until 1999 when they finally appeared in the International Journal for Quality and Health Care.

1977USReport on the Medical Insurance Feasibility Mills DH
1991USHarvard Medical Practice Study (HMPS)
1995AUSTQuality in Australia Health Care Study (QAHCS)
1999USCost of Medical Injuries with Utah and Colorado (UTCOS)
1999US/AUSTA Comparison of Iatrogenic Injuries in Australia and America
1999US/AUSTA Review of Behaviour and Quality of Care
2001AUSTIatrogenic Injury in Australia

"Brent James: Injuries, Those were injuries, those 3,996. The fascinating thing was the overlap. Among 3,996 confirmed injuries, 138 or 3.5% resulted because of a human error."

Minimising Harm to Patients in Hospital. Broadcast Monday 1 October 2001. Radio National. With Dr Brent James, Executive Director of Intermountain Health Care in Salt Lake City, Utah.

"Most problems result from a sequence of system failures rather than a single mistake by an individual."

Data for Action, A key to safer health care, Safety and Quality Council, 1/8/01.

"The causes of iatrogenic injury appear to be systemic. The remarkable constancy of pattern across the Australian and US health care systems for serious injuries bears witness to the fact that despite all of the differences in structure, training and practice, similar patterns of iatrogenic injury are observed."

Iatrogenic Injury in Australia. A report prepared by the Australian Patient Safety Foundation, WB Runciman, October 2001, p 106

"I believe the system is much more often responsible for problems than individual practitioners."

Dr Ross Wilson, Radio National ABC, 7 July 1997. [QACHS]

Brent James: ... For example, my current Big Six list, this is based upon expert opinion, so it's probably going to get changed.

An examination of real time adverse events in hospitals in the US reveals the likely source of the underlying patterns of adverse events which exist almost uniformly across the system.

1. Adverse drug events and drug reactions (in many cases a first time unpredictable reaction)
2. Hospital acquired infections
3. Bed sores or pressure sores
4. Venus thromboembolism
5. Patient falls
6. Blood product transfusions

Minimising Harm to Patients in Hospital.

If a three-month prognosis is included in a study of adverse events the results change dramatically.

"However, after considering 3-month prognosis and adjusting for the variability and skewness of reviewers' ratings, clinicians estimated that only 0.5% (95% CI, 0.3%-0.7%) of patients who died would have lived 3 months or more in good cognitive health if care had been optimal, representing roughly 1 patient per 10,000 admissions to the study hospitals."

"Conclusions: Medical errors are a major concern regardless of patients' life expectancies, but our study suggests that previous interpretations of medical error statistics are probably misleading. Our data place the estimates of preventable deaths in context, pointing out the limitations of this means of identifying medical errors and assessing their potential implications for patient outcomes."

Estimating Hospital Deaths Due to Medical Errors, Preventability is in the Eye of the Reviewer, Australian Medical Journal, 25 July 2001.

The number of deaths from adverse events are in the eye of the beholder.

"ABS data suggest 88.5 deaths per year can be attributed to adverse events as a direct underlying cause of death, but this increases to 2,678 deaths per year if you count where an adverse event may have contributed to their death. On the other hand, extrapolation of coronial data suggests approximately 700 patients may suffer an adverse event that contributes to their death each year, while the results of the Quality in Australian Health Care Study suggest a range between 8,600 and 18,000 deaths per year."

Media Release. Data for Action: A key to safer health care.
Safety and Quality Council. 8 August 2001.

"The figure most often quoted by the media is from the Quality of Australian Health Care Study, which reported and adverse event rate of 16.6 per cent associated with hospital admissions. However, reanalysis of the study following the methods of a similar study in the US found that the Australian and US studies had a virtually identical rate of serious adverse events – about 2 per cent of cases (1.7 per cent leading to serious disability and 0.3 per cent to death). It is thought that overall, about 10 per cent of hospitals admissions in Australia and other developed countries are likely to be associated with an adverse event. Most of these are simple problems."

First National Report on Patient Safety. Safety and Quality Council. August 2001.


In the eight years since the QAHCS was first published, the priorities in improving the quality of health care and making medical treatment safer are now just being heard above the headlines of "18,000 people killed each year from medical mistakes".

Remarkably the identified problem areas have been known for many years.

Any one of them could have been nominated by any active experienced medical practitioners over the last 20 years.

There is a strong desire among all professionals in the health care system to strive for greater quality and safer care.

However, a desire and good will is not enough.

There are currently 230 million transactions between the medical system and patients each year in Australia.

Health care systems are expensive and medical intervention, particularly in the frail and elderly, is high risk and becoming riskier.

A safer health care system will certainly add costs to health care and those costs eventually have to be born by those who demand a safer and better system.

Don't put faith in hospital care, expert warns
From: The Australian October 28, 2008 12:00AM

PATIENTS need to ditch the "it'll be right" attitude to hospital visits and take more responsibility for their own care, a health expert says.

It has been widely accepted for the past decade that about one in 10 Australian patients will have something go wrong during a hospital visit, University of NSW Institute of Health Innovation director Jeffrey Braithwaite said.

Australian Medical Association president Rosanna Capolingua said the reason things were more likely to go wrong in hospitals now than in the past was because the system was underfunded.

“Sure, patients do have a role in self-responsibility but I don't think it can be matched with the role that the system has in responsibility to the patient,” she told AAP.

“Things are more likely to go wrong in hospitals because the system is underfunded, stretched and under pressure and then there are system failures that occur.”

[data, sources]

From: Medical Error Stats

New report says 1500 people die each year in Australian public hospitals because of overcrowding
A UNSW report for the Australasian College of Emergency Medicine also states that Perth’s big hospital emergency departments were the worst in the country for overcrowding.
Source: "Dying risk up 30% in crowded hospitals," The West, 10.09.08.

Dying risk ‘up 30pc in crowded hospitals’ [via Internet Archive]
10th September 2008, 6:00 WST

People who need treatment in Perth’s overcrowded hospital emergency departments face as much as a 30 per cent higher risk of dying,a national summit on hospital overcrowding will warn this week.
A University of NSW report for the Australasian College of Emergency Medicine meeting in Melbourne on Friday estimates more than 1500 people die in Australia’s public hospitals each year because of overcrowding.

Australian Medical Association WA emergency medicine spokesman Dave Mountain, who will speak at the summit, said WA faced some of the worst levels of overcrowding and the situation had reached critical levels in Perth hospitals in recent weeks.

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