From The Globe:
This story notes that “when patients were autopsied, major errors related to the principle diagnosis or underlying cause of death were found in one of four cases. In one of 10 cases, the error appeared severe enough to have led to the patient’s death.”
So, it is bad news that all of the New England states report low autopsy rates in cases of unexpected deaths. Personally, it’s sad that NC also reports a low rate. The Raleigh News & Observer did a similar same story in 1995.
by Marshall Allen ProPublica, Dec. 15, 2011, 12:36 p.m.by Marshall Allen, ProPublica, Dec. 15
When Renee Royak-Schaler unexpectedly collapsed and died on May 22, no one ordered anautopsy.
Not the doctors at Howard County General Hospital in Columbia, Md., where the 64-year-old professor and cancer researcher was pronounced dead.
Not the Maryland Office of the Chief Medical Examiner, which passed on the case because no foul play was involved.
And not Royak-Schaler’s physicians at Johns Hopkins University School of Medicine who had diagnosed cancer in her hip two days beforehand but acknowledged they didn’t know what had caused her unforeseen death.
A half-century ago, an autopsy would have been routine. Autopsies, sometimes called the ultimate medical audit, were an integral part of American health care, performed on roughly half of all patients who died in hospitals. Today, data from the Centers for Disease Control and Prevention show, they are conducted on about 5 percent of such patients.
As Royak-Schaler’s husband, Jeffrey Schaler, discovered, even sudden unexpected deaths do not trigger postmortem reviews. Hospitals are not required to offer or perform autopsies. Insurers don’t pay for them. Some facilities and doctors shy away from them, fearing they may reveal malpractice. The downward trend is well-known — it’s been studied for years.
What has not been appreciated, pathologists and public health officials say, are the far-reaching consequences for U.S. health care of minuscule autopsy rates.
Diagnostic errors,which studies show are common, go undiscovered, allowing physicians to practice on other patients with a false sense of security. Opportunities are lost tolearn about the effectiveness of medical treatments and the progression ofdiseases. Inaccurate information winds up on death certificates, undermining thereliability of crucial health statistics.
It was only because of Royak-Schaler’s connections that her case ended differently. Her colleagues at the University of Maryland School of Medicine urged her husband to authorize an autopsy and volunteered to conduct it for free.
In her case, as in so many, the autopsy revealed a surprise: Royak-Schaler, the renowned cancer researcher, had cancer ravaging her body — in her lungs, kidneys ,abdomen and the marrow of her bones. A blood clot, likely related to thetumors, caused her sudden death.
Jeffrey Schaler has wrestled with anger that his wife wasn’t diagnosed sooner but said knowing how she died was better than not.
“There’s a sense of peace that accompanies that knowledge,” he said.
For the last year, ProPublica, PBS “Frontline” and NPR have probed America’s deeply flawed system of death investigation [1], focusing primarily on forensic autopsies, which are conducted by coroners’ offices and medical examiners when there is suspicion of an unnatural death. State laws vary, but the preponderance of deaths that occur in hospitals are considered natural. Whendeaths are unexplained, unobserved or within 24 hours of admission, hospitalsmay be required to report them to local coroners or medical examiners, but such agencies rarely take hospital cases.
We’re saps for top ten lists, even though we find the gimmick annoying. But, we are big fans of Joe and Terry Graedon. We’ve been following both the print and radio versions of “The People’s Pharmacy” since our days in the NC’s Research Triangle. They offer solid advice about meds
and also know the difference between quackery and home remedies. And where else
can you get Milk of Magnesia deodorant?
So we can forgive all 18 top ten lists in their new book “Top Screwups Doctors Make and How to Avoid Them.” Joe Graedon believes his mother’s 1996 death was caused by medical errors at Duke Hospitals. But, instead of suing, he tells the tale of how he and his partner/wife worked with Duke to improve care. They describe it as a “slow and frustrating” process, but think that Duke Hospital is now a safer place.
So, we offer this link and note the Boston contributors to the book. They include Harvard’s Jerry Avorn and David Bates, the head of The Center for Patient Safety Research and Practice at the Brigham. Also contributing, couple of the best sources on drug safety around – Curt Furberg of the Wake Forest School of Medicine and Thomas Moore of the Institute for Safe Medicine Practices.
We refer you to these Demon Deacons and the Blue Devils with one caveat: Go Heels! We’ve got a UNC grad/NC native in the family. So, while he’s a Tar Heel born and a Tar Heel bred, here’s hoping that medical mistake will never render him Tar Heel dead.
Before you write off these folks, note that a recent survey of doctors by the Massachusetts Medical Society found that a growing number of doctors support the idea of a single-payer system. More than 40 percent, up from 34 percent last year. So do a lot of folks at Occupy Boston.
OVERVIEW: While the Massachusetts health reform law of 2006, widely regarded as the model for the new federal health law, reduced the uninsured population in the state, it did so at the cost of rapidly rising underinsurance, increased health care premiums, and a financial crisis among the state’s safety-net hospitals and community health centers. And the financial burden of the reform has fallen disproportionately on lower-middle-class families.
Those are some of the findings in a new, exhaustively documented report on the outcomes of the Massachusetts reform law released by Mass-Care and Massachusetts Physicians for a National Health Program. The report draws on hundreds of sources, including academic studies, government statistics and scientific surveys, in the first compilation of its kind.
EXECUTIVE SUMMARY
The Massachusetts Health Reform Law of 2006 expanded Medicaid coverage for the poor and made available publicly subsidized private health insurance for additional low-income residents of the state. It also mandated that all but the poorest uninsured residents either purchase private health insurance or pay a substantial fine (up to $1,212 in 2011). Smaller fines (up to $295 per employee) were also levied on employers who fail to offer insurance.
Four years after full implementation of the law, Massachusetts has not achieved universal coverage, although one-half to two-thirds of the previously uninsured now have some type of insurance policy. Most of the gains in coverage have come from expansions in publicly subsidized insurance. This largely represented a shift of patients from the state’s former Free Care Pool, which compensated hospitals and community health centers directly for care of the uninsured, to private insurance plans, which is a more costly way to provide care. The reform did not lead to a sustained increase in employer-sponsored coverage, but did slow declining employer coverage. Instead of dropping coverage, employers in Massachusetts have increased cost sharing, shifting costs on to employees, leading to rapidly rising underinsurance after health reform. The use of high-deductible plans more than tripled for residents with private insurance, and good insurance coverage at small businesses all but disappeared over a few short years after reform.
Reform has had a positive impact on access to care in the state, but this impact has affected a modest share of residents, and for some patients has been negative. For example, some low-income patients who previously received completely free care under the state’s prior free care program faced new co-payments and premiums after becoming insured, which impeded their access to care. Reform has not reduced the burden of medical bills and medical bankruptcy on Massachusetts’ families.
The growth of residents with insurance coverage has exacerbated a primary care shortage in Massachusetts by increasing wait times for appointments and decreasing the portion of physicians accepting new patients, creating access problems even for those with coverage. Reform did not reverse growing use of the state’s emergency departments for care, despite expectations that expanding insurance coverage would reroute patients through primary care offices. There is no evidence as of yet that expanding insurance coverage has had an impact on health outcomes or disparities in health outcomes. Reform has also created a financial crisis for safety net providers that specialize in care for low-income communities and the uninsured, by shifting resources away from safety net providers while patient demand for safety net care has actually increased.
The public cost of reform has been high, exceeding $800 million in fiscal 2009 for a state with a total budget of $32.5 billion. However, federal taxpayers paid for the bulk of the law’s public expenses. The state has made a broad range of cuts to the original law in order to its keep costs down, cutting back coverage for over 30,000 documented immigrants, curtailing some benefits, increasing cost sharing, and increasing the share of enrollees required to pay premiums. Substantial funds from the federal stimulus bill were also used to sustain the reform law, but this was a short-term fix only.
Public payments account for only a portion of the reform law’s costs. A central premise of the law was that the state, employers, and individuals would all have to sacrifice financially to approach the goal of universal coverage. This premise of “shared responsibility” for the costs of the reform was in many ways disingenuous. Although employers, individuals, state and federal government have shared the burden of increased costs roughly equally, this overlooks the fact that governments pass on their spending to taxpayers, and employers pass on their costs to employees. The actual burden of health reform was regressive, with increased spending after health reform falling disproportionately on lower-middle income residents.
The reform failed to “bend the cost curve” in Massachusetts because it contained no significant cost-control provisions. Health care costs in Massachusetts are higher than in any other state in the nation, and reform has been found to accelerate the rising costs of employer-sponsored health care. There is general agreement that the Massachusetts reform is itself not sustainable without effective cost control.
Massachusetts enjoyed favorable circumstances at the outset of reform, such as previously high levels of spending on health care for the poor, high personal incomes, and relatively low rates of uninsurance. Without controlling costs, national reform will run up against the same difficulties as Massachusetts: growth in public insurance coverage will prove unsustainable and will accompany the rapid erosion of private insurance benefits, while modest gains in access to care will be threatened in the short term by unsustainably high costs that are increasingly shifted on to patients.
While Massachusetts health reform has enjoyed support from a majority of residents in the state, that support has declined since national health reform instigated a broader debate over alternatives to the Massachusetts plan. Moreover, while residents support the Massachusetts reform law over no change at all, they have expressed increasing skepticism that the law is working for vulnerable communities, and more residents report that the law is hurting them than helping them.
We believe that the data in this report should give pause to those concerned with national health care reform. Although not without its successes, the Massachusetts reform has not addressed the fundamental deficiencies in the health care system – treating symptoms rather than causes – and even its modest successes are unsustainable for the state and Massachusetts residents.
Check out #chs11 f for tweet from the Connected Health Symposium in Boston. Each year, Partners sponsors this meeting to look at how the Internet and mobile communication are changing the health care system. Here’s a link to the Tweetstream and a few samples below from a session on social networking and health.
| “ | RT @MGHDiabetesEd: “online patient communities can increase engagement, decrease isolation.” #chs11 | |||
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| “ | @taracousphd at #SoMe panel at #chs11: 35% of young people search for #healthcare informaton online | |||
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| “ | Giving patients the choice to use an alias-based identity on social networks is a key way to address privacy concerns #chs11 | |||
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| “ | @dsgold How so? Alias identity does not equal unidentifiable, does it? I’d be concerned this is a false sense of security. #chs11 | |||
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| “ | Facebooking health @taracousphd facebook campaigns have huge opportunity for reaching teens, can use it for health literacy #chs11 | |||
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| “ | @lisagualtieri : There are credit #literacy programs for teenagers, why not more health literacy ones? #chs11 | |||
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| “ | We need to be inter-generational in our social media “prescription” including seniors as well as youth #chs11 | |||
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| “ | Social media can help make a disease more than just a disease for teens @drjosephkim #chs11 | |||
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| “ | @drdannysands telling about how he prescribed acor to @epatientdave & it save his life #chs11 #s4pm | |||
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| “ | Next up, Facebooking Health moderated by my wonderful #TUSM colleague @lisagualtieri #chs11 | |||
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| “ | @meyouhealth Chris Catter shows first ever social graph to visually render well-being among participants in social networks #chs11 | |||
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| “ | CDC traditional data tracked same as social media during H1N1 #chs11 | |||
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| “ | should MDs, nurses, etc recommend online pt communities? -yes! #chs11 | |||
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Margaret Morganroth Gullette’s op-ed in last week’s NYTimes dared to suggest that our fears about Alzheimer’s
may be overblown. The Brandeis-based writer said:
The mere whiff of perceived memory loss can have terrible consequences in an insecure economy in which midlife workers are
regularly (and illegally) laid off on account of their age. This epidemic of anxiety around memory loss is so strong that many older adults seek help for the kind of day-to-day forgetfulness that once was considered normal …Greater public awareness of Alzheimer’s, far from reducing the ignorance and stigma around the disease, has increased it.
Today’s letters to the editor included several outraged responses
Having witnessed the disease firsthand, I can truly say there is something worse than death…I truly hope that Margaret
Morganroth Gullette and those she loves never experience the disease as my family has. I implore her not to use her public platform to minimize the horror that is Alzheimer’s.
But, Douglas Powell, described as the author “The Aging Intellect” and a psychology instructor at the Harvard Medical
School, came to her defense
Studies that followed up mildly impaired elders for three to five years found that a large minority remained stable and about 14 percent returned to normal. No one yet knows why.
In the old days, hospitals were not allowed to admit medical errors to patients and families. Today, at some hospitals, that has changed. Today’s Globe story on a lawsuit over a fatal overdose of blood thinner contains this statement from Mass General.
A spokeswoman for Massachusetts General Hospital said in a statement yesterday that the hospital regrets the error, and “our hearts go out to Mrs. Oswald’s family.’’
Spokeswoman Peggy Slasman said that the hospital has enacted new guidelines for the administering of Lepirudin. One plan, according to a hospital report, is to improve the way doctors review and approve new dose infusions.
“As soon as we understood what had happened, we apologized and explained the situation to Mrs. Oswald’s family,’’ said Slasman. “We undertook a thorough and extensive internal review of the case, and we communicated with family members throughout this process. As a result of this event, we have made some specific changes to our practices to reduce the chance of such an event from occurring again.’’
Could this be a new approach to the hospitals case in a malpractice suit? Worth checking into. In the meantime, there is now a group that recognizes that medical errors are hard for both clinicians and their patients. They’ve generated a nasty bit of jargon, but their approach is unprecedented.
Medically Induced Trauma Support Services (MITSS), Inc. is a non-profit organization founded in June of 2002 whose mission is “To Support Healing and Restore Hope” to patients, families, and clinicians who have been affected by an adverse medical event.
Medically induced trauma is an unexpected outcome that occurs during medical and/or surgical care that affects the emotional well being of the patient, family member, or clinician.
Here at BHN, we don’t go much for National… Fill in the Blank…Week. But, we offer this video on patient safety by the Boston-based National Patients Safety Foundation anyway.
Two items of note in the local press.
In the Globe, master obit writer Bryan Marquard offers a remembrance of Angie Scardino, the Franklin women who allowed the former Globe reporter Alice Dembner to chronicle her life after a hip fracture. According to the Mayo clinic, nearly half of all hip fractures occur in adults older than 80 years. While bone loss is a factor, most hip fractures are caused by falls.
Mrs. Scardino, who most recently lived with her daughter in Franklin, but always thought of the house she and her late husband bought in Scotia, N.Y., as her home, died of congestive heart failure Friday at Beth Israel. She was 86.
Allowing herself to become the public face of an injury that takes the lives of so many older patients was, in many ways, uncharacteristic of Mrs. Scardino, who was so private she usually avoided trading stories with friends about the ailments of age.
Also, Rachel Zimmerman over at Commonhealth, offers a Q &A. with Dr. Roseanna Means who “started the nonprofit, Women of Means, in 1999, when she realized that help for the homeless was primarily geared toward men and overlooked the specific medical needs of women. Earlier this month, Dr. Means was presented with a Community Health Leaders Award for her work by the Robert Wood Johnson Foundation.” She begins with the Q: How does a pedicure constitute medical care?
Finally, on the blogs, check out this week’s Health Wonk Review, which features another Q & A, this one with Evan Falchuk, President of the Boston-based company Best Doctors. Speaking to local consultant Dave Williams, Falchuk describes his company this way:
Evan Falchuk: We sell an employee benefit to companies that they give for free to their employees. We help people get the right diagnosis and the right treatment. The way we do it is by collecting information from the patient, doing an interview, compiling records, having doctors analyze all the information and then consulting with experts from our Best Doctors database to figure out the right course of treatment.
This week’s HWR is brought to you by The Insure Blog.
Cancer patients hear it all the time – Be brave…you can win this battle…lick cancer…etc…
Some of them are sick of it. Cancer, they say, stinks. A positive attitude and all the pink ribbons in the world won’t save someone whose chemo has failed, they say. And, they are tired of all the chirpy advice. (See writer Barbara Erinreich’s comments from a 2001 Harper’s article, “Welcome to Cancerland.”)
All of this is now being hashed out among three local bloggers. It started when prolific blogger Kevin Pho of New Hampshire ( Billed as “Social media’s leading physician voice.”) posted a chapter from a new book by e-patient Dave. Dave deBronkart the energetic embodiment of the connected patient, writes about “hope as a resource” in his take of surviving Kidney cancer — “Laugh, Sing and Eat like aPig.”
Some people with cancer object to the constant barrage of “be positive” rhetoric, as reflected in comments on the site. One goes like this:
… this excerpt makes me cringe inside. As someone with metastatic cancer, I often hear from friends and others who have read accounts of people who appear to have cured themselves of cancer by having the right attitude. The media loves (sic)to trot out this theme. The suggestion is that anyone who is sufficiently upbeat can prevail over their cancer. And, by extension, that anyone who does poorly must have the wrong attitude…
People with hepatitis or diabetes or broken bones do not get told to adjust their attitude. They are offered treatment regimens and told to stick with them. But cancer patients, particularly those without solid treatment options, are constantly urged to “think positive.”
Now, BIDMC CEO Paul Levy weighs in.
I started to write this post to offer my appreciation to Kevin, MD, for posting a chapter of ePatient Dave’s Laugh, Sing, and Eat Like a Pig, and for Dave and his publisher for graciously allowing anybody to read the entire chapter without having to buy the book. The story is compelling, and this particular chapter is especially so.
But that was before I read the exchange of comments on Kevin’s blog. At least one commenter took offense at her perception that Dave was glorifying the role of hope in the treatment of cancer, and in so doing might be disparaging people who do not experience that hope, suggesting that they are somehow weak and inadequate. As you read through Dave’s response and that of other observers, it becomes clear that he certainly did not intend to suggest such a conclusion.
