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This article published in the prestigious Journal of the American Medical Association (JAMA) is the best article we have ever seen written in the published literature documenting the tragedy of the traditional medical paradigm.

This information is a follow up of the Institute of Medicine report which hit the papers in December of 1999, but the data was hard to reference as it was not in peer-reviewed journal. Now it is published in JAMA which is the most widely circulated medical periodical in the world.

The author is Dr. Barbara Starfield of the Johns Hopkins School of Hygiene and Public Health and she describes how the US health care system may contribute to poor health.

THESE ARE NUMBERS OF USA DEATHS PER YEAR BY CAUSE:
12,000 -- unnecessary surgery
7,000 -- medication errors in hospitals
20,000 -- other errors in hospitals
80,000 -- infections in hospitals
106,000 -- non-error, negative effects of drugs


These total to 225,000 deaths per year from iatrogenic causes!


Iatrogenic is defined as induced in a patient by a physician's activity, manner, or therapy. Used especially of a complication of treatment.

Dr. Starfield offers several warnings in interpreting these numbers:
First, most of the data are derived from studies in hospitalized patients.
Second, these estimates are for deaths only and do not include negative effects that are associated with disability or discomfort.
Third, the estimates of death due to error are lower than those in the IOM report.

If the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000. In any case, 225,000 deaths per year constitutes the third leading cause of death in the United States, after deaths from heart disease and cancer. Even if these figures are overestimated, there is a wide margin between these numbers of deaths and the next leading cause of death (cerebrovascular disease).

Another analysis concluded that between 4% and 18% of consecutive patients experience negative effects in outpatient settings,with:
116 million extra physician visits
77 million extra prescriptions
17 million emergency department visits
8 million hospitalizations
3 million long-term admissions
199,000 additional deaths
$77 billion in extra costs


The high cost of the health care system is considered to be a deficit, but seems to be tolerated under the erroneous assumption that better health results from more expensive care.

However, evidence from a few studies indicates that as many as 20% to 30% of patients receive inappropriate care.

Shockingly, an estimated 44,000 to 98,000 among them die each year as a result of medical errors.

These type of statistics might be tolerated if it resulted in better health, but does it? Out of thirteen countries in a recent comparison, the United States ranks an average of twelfth (second from the bottom) for 16 available health indicators. More specifically, the ranking of the US on several indicators was:


13th (last) for low-birth-weight percentages
13th for neonatal mortality and infant mortality overall
11th for postneonatal mortality
13th for years of potential life lost (excluding external causes)
11th for life expectancy at 1 year for females, 12th for males
10th for life expectancy at 15 years for females, 12th for males
10th for life expectancy at 40 years for females, 9th for males
7th for life expectancy at 65 years for females, 7th for males
3rd for life expectancy at 80 years for females, 3rd for males
10th for age-adjusted mortality

The poor performance of the US was recently confirmed by a World Health Organization study, which used different data and ranked the United States as 15th among 25 industrialized countries.

There is a perception that the American public "behaves badly" by smoking, drinking, and perpetrating violence." However the scientific data absolutely does not support this claim. The proportion of females who smoke ranges from 14% in Japan to 41% in Denmark; in the United States, it is 24% (fifth best). For males, the range is from 26% in Sweden to 61% in Japan; it is 28% in the United States (third best).


The US ranks fifth best for alcoholic beverage consumption.
The US has relatively low consumption of animal fats (fifth lowest in men aged 55-64 years in 20 industrialized countries) and the third lowest mean cholesterol concentrations among men aged 50 to 70 years among 13 industrialized countries.

These estimates of death due to error are lower than those in a recent Institutes of Medicine report, and if the higher estimates are used, the deaths due to iatrogenic causes would range from 230,000 to 284,000.

Even at the lower estimate of 225,000 deaths per year, this constitutes the third leading cause of death in the US, following heart disease and cancer. Lack of technology is certainly not a contributing factor to the US's low ranking. Among 29 countries, the United States is second only to Japan in the availability of magnetic resonance imaging units and computed tomography scanners per million population. (17)  Japan, however, ranks highest on health, whereas the US ranks among the lowest.


It is possible that the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the US, high use of diagnostic technology may be linked to more treatment.


Supporting this possibility are data showing that the number of employees per bed (full-time equivalents) in the United States is highest among the countries ranked, whereas they are very low in Japan, far lower than can be accounted for by the common practice of having family members rather than hospital staff provide the amenities of hospital care.

Journal American Medical Association July 26, 2000;284(4):483-5

Author/Article Information

Author Affiliation: Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, Baltimore, Md. Corresponding Author and Reprints: Barbara Starfield, MD, MPH, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, 624 N Broadway, Room 452, Baltimore, MD 21205-1996 (e-mail: bstarfie@jhsph.edu).

References

1. Schuster M, McGlynn E, Brook R. How good is the quality of health care in the United States?
Milbank Q. 1998;76:517-563.

2. Kohn L, ed, Corrigan J, ed, Donaldson M, ed. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

3. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press; 1998.

4. World Health Report 2000. Accessed June 28, 2000.

5. Kunst A. Cross-national Comparisons of Socioeconomic Differences in Mortality. Rotterdam, the Netherlands: Erasmus University; 1997.

6. Law M, Wald N. Why heart disease mortality is low in France: the time lag explanation. BMJ. 1999;313:1471-1480.

7. Starfield B. Evaluating the State Children's Health Insurance Program: critical considerations.
Annu Rev Public Health. 2000;21:569-585.

8. Leape L.Unecessarsary surgery. Annu Rev Public Health. 1992;13:363-383.

9. Phillips D, Christenfeld N, Glynn L. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-644.

10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205.

11. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology and medical error. BMJ. 2000;320:774-777.

12. Wilkinson R. Unhealthy Societies: The Afflictions of Inequality. London, England: Routledge; 1996.

13. Evans R, Roos N. What is right about the Canadian health system? Milbank Q. 1999;77:393-399.

14. Guyer B, Hoyert D, Martin J, Ventura S, MacDorman M, Strobino D. Annual summary of vital statistics1998. Pediatrics. 1999;104:1229-1246.

15. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14:499-511.

16. Donahoe MT. Comparing generalist and specialty care: discrepancies, deficiencies, and excesses. Arch Intern Med. 1998;158:1596-1607.


17. Anderson G, Poullier J-P. Health Spending, Access, and Outcomes: Trends in Industrialized Countries. New York, NY: The Commonwealth Fund; 1999.

18. Mold J, Stein H. The cascade effect in the clinical care of patients. N Engl J Med. 1986;314:512-514.

19. Shi L, Starfield B. Income inequality, primary care, and health indicators. J Fam Pract.1999;48:275-284.

 


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