By Michael L. Millenson
Forget for a moment the familiar scenes of action and outraged reaction that are playing out in our long-running national debate over how best to provide access to health care for every American. Instead, ask one simple question: what happens in the doctor’s office or hospital once access is achieve
I set out to write a book addressing that question almost twenty years ago. I thought myself well qualified: I’d written about health care for a decade for the Chicago Tribune while receiving various awards and other recognition. But it didn’t take long for a painful realization to set in of how naïve I really was.
Digging through hundreds of studies, articles and other first-hand sources stretching back for decades, I was stunned to discover that repeated evidence of unsafe, ineffective, wasteful and downright random care had had no effect whatsoever on how doctors treated patients. Literally none. Moreover, the few professionals who understood this truth couldn’t talk about it in public without endangering their careers or engendering vitriol from peers.
Fortunately, I had no academic or clinical career to imperil. In the conclusion to Demanding Medical Excellence: Doctors and Accountability in the Information Age, I gave vent to anger and indignation. I wrote:
From ulcers to urinary tract infections, tonsils to organ transplants, back pain to breast cancer, asthma to arteriosclerosis, the evidence is irrefutable. Tens of thousands of patients have died or been injured year after year because readily available information was not used – and is not being used today – to guide their care. If one counts the lives lost to preventable medical mistakes, the toll reaches the hundreds of thousands.
The only barrier to saving these lives is the willingness of doctors and hospital administrators to change.
Demanding Medical Excellence came out in October, 1997. What progress has been made since then, and where we have fallen short? I address that question in a short article, “The Long Wait for Medical Excellence,” in the October, 2013 issue of Health Affairs. The purpose of this blog entry is to recap some of what’s said there (for you non-subscribers) and to add a few impolite observations that don’t jibe with the rules of a peer-reviewed journal.
Demanding Medical Excellence shone a spotlight on medical error, evidence-based medicine, health information technology, population health and patient empowerment well before those topics achieved their current prominence. A few labels have changed since then. “Managed care,” for instance, has morphed into “accountable health care” (with a few twists), while the plea to employers and insurers to “buy right” has been repackaged as “value-based purchasing.”
Far more importantly, conversations about quality of care problems that were once suspect or even taboo have become open and officially approved. Still, a tendency towards “little white lies” persists in a shying away from confronting head-on the agonizingly slow pace of our progress. I think the tendency shows up in all areas of health care, but it is particularly evident with medical error. I confess that I’ve been among the guilty.
That paragraph I just cited about the toll on patients (“From ulcers to urinary tract infections…”)? My editors didn’t spot it, but I deliberately made the total smaller than it should have been. Elsewhere in Demanding Medical Excellence, I had written that there were “about 180,000 deaths and 1.3 million injuries each year owing to medical treatment” in hospitals. That was based on my extrapolation of studies from the late 1970s and early 1990s. However, in the book’s conclusion, I lumped in deaths from a lack of evidence-based care and low-balled the whole thing.
In my defense, I was writing at a time when the Institute of Medicine (IOM) had not yet not breathed a word about “overuse, underuse and misuse,” much less pronounced a nearly six-figure death toll from mistakes. Although I was no longer a reporter, I was worried about being portrayed as a sensation-seeking journalist.
Yet even today, many in the quality field hesitate to stare directly into the face of the grim statistics on the persistence of the medical error problem. Recall that I used data from decades ago to calculate 180,000 preventable inpatient deaths annually. In 2004, HealthGrades ended up with 195,000 deaths, about the same number. In 2009, an investigation by Hearst journalists found 200,000 deaths. Most recently, a September, 2013 study in the Journal of Patient Safety put the toll at 210,000 to 400,000 deaths per year.
By way of comparison, the 1998 report on errors from the IOM estimated that 44,000 to 98,000 patients die each year in hospitals from preventable mistakes. The Agency for Healthcare Research and Quality (AHRQ), using a different methodology, recently estimated the number to be 97,000.
Put it all together and this is what you’ve got: for the past decade (or, maybe, for several decades), 100,000 Americans (or maybe upwards of 200,000 Americans) have lost their lives each year in hospitals through preventable medical mistakes. Add it up: a million preventable deaths? Two million? Plus preventable injuries? Pick your time frame and your toll.
Now, consider that 15 years after the IOM error report there is no reliable estimate at all of the death and injury toll in the outpatient environment. Why? And why no outrage?
In a 2010 Health Affairs blog, “Why We Still Kill Patients,” I bluntly blamed the lack of progress on a combination of errors’ invisible consequences, professional inertia and the income hospitals quietly reap from substandard care. I believe that new standards of transparency, in addition to government and private sector financial incentives, are making care safer (I’ve written about a personal experience with my wife.) But we’ll have to wait and see what the data show.
Also on the bright side, there is certainly evidence that care is getting more evidence-based. So much so that clinicians with short memories are kvetching about process of care measures. They forget that years of studies and even hectoring by the American Medical Association (AMA) couldn’t get doctors to consistently do something as simple as administering beta blockers to appropriate heart attack patients. However, after Medicare made this a publicly reportable “core measure,” the rate soared. “What gets measured gets managed” is a piece of business world wisdom that has helped prompt dramatic improvement in health care.
The current debates about which measures to keep and use are a sign of progress. Not long ago, measurement itself was suspect, and the AMA considered the very word “guideline” an implicit insult to physician judgment. Its preferred term was “practice parameter.”
In just the last few years, there have also been enormous strides in adopting health information technology (HIT), enabling care to be measured, managed and improved. I wrote of an information revolution “owing more to laptops than to lab coats” at a time when Web browsers were a new technology, and mobile computing was the watch worn by Dick Tracy in a comic strip. Today, thanks to payments of billions of federal dollars to doctors and hospitals through the HITECH Act, most providers are rapidly catching up to the 20th century and some are in the 21st.
In the health IT realm, clinical pioneers began using computerized decision support in the mid-1950s. I admit it never occurred to me that bribery (“Take this money for computers, but promise you’ll provide ‘meaningful use’ in return”) would prove the key a half century later to unlocking its acceptance. Still, money has always been a powerful motivator, and the Affordable Care Act is filled with similar motivating provisions.
There’s one other change that doesn’t get talked about much, but is quietly crucial. “People are policy,” the saying goes. Some who were leaders in quality and safety back then are still leaders today: see, “Intermountain Health Care.” Elsewhere, in hospitals, medical groups and other institutions, there are now leaders who built careers on an embrace of quality improvement when it was far from a wise decision to do so.
Take, for example, the two clinicians writing about medical error in the Annals of Internal Medicine in 2000 who called Demanding Medical Excellence “required reading for physicians.” Both were young Harvard docs with a passion for patient safety despite substantial pushback within their own institution. One, Dr. David Bates, now directs the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital and holds senior posts in the Harvard system. His co-author, Dr. Atul Gawande, has made patient safety, practice variation and evidence-based medicine the stuff of everyday conversation through compelling articles in The New Yorker and best-selling books.
The Robert Wood Johnson Foundation, which provided the grant enabling me to write my book, is headed by Dr. Risa Lavizzo-Mourey, the former deputy administrator of what is now called AHRQ. The president of the Commonwealth Fund, Dr. David Blumenthal, is a pioneering quality and safety researcher who early on hailed the potential of HIT to improve the “moral pillars” of medicine. At Thomas Jefferson University in Philadelphia, the nation’s first School of Population Health was begun by Dr. David Nash, who pushed transparency and accountability years before it was politic to do so. There are others like them.
Demanding Medical Excellence also profiled Dr. Donald Berwick, who had founded a small non-profit with the mission of spreading quality improvement practices. Berwick went on to lead the Centers for Medicare & Medicaid Services, one of the biggest purchasers of health care in the world, and focused it on the “triple aim” of better care, better health and lower cost. Berwick is now running for governor of Massachusetts. The Institute for Healthcare Improvement that he founded most recently reported revenues of almost $43 million.
To be sure, many patients and doctors still believe that “more” care is “better” care. Their numbers, though, are likely dwindling due to the efforts of professional and consumer groups alike. Moreover, patients are being brought into economic and clinical decisions in health care in ways that seemed inconceivable in the 1990s.
When I wrote Demanding Medical Excellence, I thought the new world of quality measurement and management lay just over the horizon, but culture change can be stubbornly slow. It was nearly a century ago that Dr. Ray Lyman Wilbur, former president of the AMA and chairman of the blue-ribbon Committee on the Costs of Medical Care, wrote this: “The quality of medical care is an index of a civilization.”
It is a benchmark we’d do well to keep in mind today.
Michael L. Millenson is president of Health Quality Advisors LLC in Highland Park, IL and the Mervin Shalowitz, MD Visiting Scholar at the Kellogg School of Management.