THE QUALITY GAP: MEDICINE'S SECRET KILLER Summary
By Marc Shaffer
Most Americans assume that the trillion dollar health care system is the best in the world, and that patients can assume quality. The truth is that whether looking at deaths caused by medical errors in American hospitals, or the far more overlooked but just as deadly gap between what is best medical practice and what is routinely practiced in doctors' offices and hospitals, American health care has failed to achieve a level of safety and predictable quality that people take for granted. This segment takes a broad look at this vital yet often ignored subject.
"I am surprised at how little the public seems to understand about the gaps in the quality of care they're getting," remarks Dr. Don Berwick, head of the Institute for Healthcare Improvement. "Maybe they just trust the system and that's good . . . but the public doesn't understand how much better it could be."
Last year the National Institute of Medicine reported that between 44,000 and 98,000 Americans die each year in hospitals as a result of medical errors. Even by the lower estimate, the IOM noted, medical errors are the 8th leading cause of death in the country, ahead of car accidents, breast cancer, and AIDS. Beyond the human impact, experts cite errors and sub-optimal medicine as the most costly element of American health care. The IOM estimated the total economic impact at between $17 billion and $29 billion to the nation. Do it better, these advocates argue, and you'll not only save lives, you'll save money, too.
In 1991, New York State became the first state in the nation to rate the actual medical performance, when it released risk-adjusted mortality rates following open heart surgery for each New York hospital. A year later a lawsuit by Newsday newspaper forced the mortality rates public of New York cardiac surgeons. For the first time, patients could see real data on the performance of their surgeon and their hospital. The numbers were deeply disturbing. The chance of surviving a heart surgery differed dramatically from one hospital to another, one doctor to another.
The debate rages to this day as to whether the public release of data is good for patients, or whether it backfired by intimidating physicians into avoiding tough cases. The proponents of sunshine can point to one very compelling argument: Between 1989 and 1992 the death rate from bypass surgery in New York dropped over 40 percent.
Those opposed to public release can point to equally impressive gains made, without public disclosure, through a breakthrough collaboration among six hospitals in northern New England. In 1987, a Medicare study showed wide variation of outcomes on nine different procedures and diseases, including heart surgery. Surgeons at Dartmouth University, led by Dr. Bill Nugent, were so convinced that the report was wrong that they launched a study of their own to disprove it. They were stunned to find out that, in fact, survival rates following heart bypass surgery in northern New England did vary dramatically.
Dartmouth turned to Dr. Don Berwick for guidance. "They could have deep-sixed (their findings)," says Berwick. "Instead they decided to use the information. They decided they could learn from each other. And I think that was incredibly courageous of them." Working together the different centers shared the little things that made a difference, and most importantly dismissed with their hierarchical, fractured culture for a more respectful, team-oriented approach. The results: a 24 percent mortality drop between 1989 and 1992.
Quality breakthroughs aren't only limited to the world of highly specialized heart surgeries. At Intermountain Health Care in Utah, another convert to the quality holy war, Dr. Kim Bateman, has spearheaded a new way of treating community acquired pneumonia. Bateman's discovery wasn't some complicated new approach, but precisely the opposite - identifying the single best way to treat the disease and doing it the right way every time.
When Bennie Curry showed up at the LDS Hospital Emergency Room in Salt Lake City complaining of a deep pain in his chest, he was examined, an x-ray was taken, and the diagnosis of pneumonia was made. A little more than an hour after arrival he was given the antibiotic Rocephin. Curry, who is homeless, was later admitted to the hospital.
This seemingly run-of-the-mill routine is in fact a precise and extremely effective protocol designed by Dr. Kim Bateman and his colleagues. In 1994, Dr. Bateman was encouraged by local quality guru Dr. Brent James to examine how IHC could improve its pneumonia care, a major killer in Utah. Bateman was stunned to find that doctors were treating the disease with an endless number of approaches. "We identified 68 different combinations of antibiotics in 101 patients," said Bateman. "Is it possible that one is better than another one? And if one's better, shouldn't you use it?"
After careful study, Bateman's team agreed that Rocephin or another antibiotic was the best for treating pneumonia in nearly all cases. Dr. James has estimated that Bateman's new protocol has saved as many as 50 lives a year in the IHC system.
There remains the vexing problem of outright errors in medical care: giving the wrong medication to a patient, or too much; failing to follow up with a patient about a problem lab test; cutting off the wrong limb, or removing the wrong kidney. It is these types of errors that grab the headlines and drive debate. Medicine is cloaked in a culture of secrecy, and the threat of malpractice lawsuits only reinforces the instinct among doctors and hospitals to hide their errors from patients or surviving family members.
In February 1997, Korean War Veteran Claudie Holbrook entered the Lexington, Kentucky Veterans Administration Medical Center for the last time. He died days later of a blood clot in his lung. Although Holbrook was quite ill, he did not have to die. He was felled by a medical error, when the VA pharmacy began sending home the wrong strength of blood thinning medication.
Instead of waiting for the Holbrook family to file a claim, as is the customary practice in medical error cases, the VA took a proactive approach. After an internal investigation, Hospital attorney Ginny Hamm met with the Holbrook family. "She said, 'We were the ones that killed your dad,'" recalls Holbrook's youngest daughter Sandy Reynolds. According to Hamm and Kraman, once the evasion and hostility so typical of hospitals facing errors disappears, patients are far less angry and punitive. A recent paper by Kraman and Hamm published in The Annals of Internal Medicine showed that the Lexington VA, even with its policy of full disclosure, had the seventh lowest malpractice payouts of 36 VA's east of the Mississippi River.
Whether such candor makes sense and is ethical, as the Lexington VA believes, or serves the cause of continuous quality improvement as is debated among heart surgeons and others in New York and the Northeast, it is the wave of the future, and that's a sea-change in the culture and practice of American medicine.
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