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De:
"Luiz Meira" <luizmeira@yahoo.com>
Data: Seg Jun 4, 2001 9:03
pm
Assunto: iatrogenia nos EUA
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Jose escribio:
>>E por falar em Medicina Alternativa
alguem já viu a revista "Super Interessante "
desse mês ?
Si Jose, lei el articulo. Lo recibi de otro grupo. En caso que alguien
este interesado y no quiera comprar la revista lo puedo enviar a la lista.
Lo que quiero enviar ahora es el reporte de la AMA publicado en la
revista JAMA. Los datos sobre las muertes iatrogenicas en USA que da
Superinteresante estan tomados de ese informe. En verdad, asustadores.
Va el articulo completo abajo
Besos a todos
Gabriela
Is US Health Really the Best in the World?
Barbara Starfield, MD, MPH
Information concerning the deficiencies of US medical care has been
accumulating. The fact that more than 40 million people have no health
insurance
is well known. The high cost of the health care system is considered to be
a deficit, but seems to be tolerated under the assumption that better health
results from more expensive care, despite evidence from a few studies
indicating
that as many as 20% to 30% of patients receive contraindicated care.(1) In
addition, with the release of the Institute of
Medicine (IOM) report "To Err Is Human,"2 millions
of Americans learned, for the first time, that an estimated 44,000 to 98,000
among them die each year as a result of medical errors.
The fact is that the US population does not have anywhere near the best
health in the world. Of 13 countries in a recent comparison,(3)
the United States ranks an average of 12th (second from the bottom) for 16
available health indicators. Countries in order of their average ranking on
the health indicators (with the first being the best) are Japan, Sweden,
Canada,
France, Australia, Spain, Finland, the Netherlands, the United Kingdom,
Denmark,
Belgium, the United States, and Germany. Rankings of the United States on
the separate indicators(3) are:
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 United States was recently confirmed by the
World Health Organization, which used different indicators. Using data
on disability-adjusted life expectancy, child survival to age 5 years,
experiences
with the health care system, disparities across social groups in experiences
with the health care system, and equality of family out-of-pocket
expenditures
for health care (regardless of need for services), this report ranked the
United States as 15th among 25 industrialized countries.(4)
Thus, the figures regarding the poor position of the United States in health
worldwide are robust and not dependent on the particular measures used.
Common
explanations for this poor performance fail to implicate the health system.
The perception is that the American public "behaves badly" by smoking,
drinking,
and perpetrating violence. The data show otherwise, at least relatively. 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 data for alcoholic beverage consumption are similar: the United States
ranks fifth best. Thus, although tobacco use and alcohol use in excess
are clearly harmful to health, they do not account for the relatively poor
position of the United States on these health indicators. The data on years
of potential life lost exclude external causes associated with deaths due
to motor vehicle collisions and violence, and it is still the worst among
the 13 countries.(3) Dietary differences have
been demonstrated to be related to differences in mortality across
countries,(5) but the United States 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.(6)
The real explanation for relatively poor health in the United States
is undoubtedly complex and multifactorial. From a health system viewpoint,
it is possible that the historic failure to build a strong primary care
infrastructure
could play some role. A wealth of evidence3
documents the benefits of characteristics associated with primary care
performance.
Of the 7 countries in the top of the average health ranking, 5 have strong
primary care infrastructures. Although better access to care, including
universal
health insurance, is widely considered to be the solution, there is evidence
that the major benefit of access accrues only when it facilitates receipt
of primary care.(3, 7) The health
care system also may contribute to poor health through its adverse effects.
For example, US estimates (8-10)
of the combined effect of errors and adverse effects that occur because of
iatrogenic damage not associated with recognizable error include:
12,000 deaths/year from unnecessary surgery
7000 deaths/year from medication errors in hospitals
20,000 deaths/year from other errors in hospitals
80,000 deaths/year from nosocomial infections in hospitals
106,000 deaths/year from nonerror, adverse effects of medications
These total to 225,000 deaths per year from iatrogenic causes. Three caveats
should be noted. First, most of the data are derived from studies
in hospitalized patients. Second, these estimates are for deaths only and
do not include adverse effects that are associated with disability or
discomfort.
Third, the estimates of death due to error are lower than those in the IOM
report.(1) 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).
One analysis overcomes some of these limitations by estimating adverse
effects in outpatient care and including adverse effects other than
death.(11) It concluded that between 4% and 18% of consecutive patients
experience adverse 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, and $77 billion in extra costs (equivalent to the
aggregate cost of care of patients with diabetes).(11)
Another possible contributor to the poor performance of the United States
on health indicators is the high degree of income inequality in this
country.
An extensive literature documents the enduring adverse effects of low
socioeconomic
position on health; a newer and accumulating literature suggests the adverse
effects not only of low social position but, especially, low relative social
position in industrialized countries.(12)
Among the 13 countries included in the international comparison mentioned
above, the US position on income inequality is 11th (third worst). Sweden
ranks the best on income equality (when income is calculated after taxes and
including social transfers), matching its high position for health
indicators.
There is an imperfect relationship between rankings on income inequality and
health, although the United States is the only country in a poor position
on both (B.S., unpublished data, 2000).
An intriguing aspect of the data is the differences in ranking for the
different age groups. US children are particularly disadvantaged, whereas
elderly persons are much less so. Judging from the data on life expectancy
at different ages, the US population becomes less disadvantaged as it ages,
but even the relatively advantaged position of elderly persons in the United
States is slipping. The US relative position for life expectancy in the
oldest
age group was better in the 1980s than in the 1990s.(13)
The long-existing poor ranking of the United States with regard to infant
mortality(14) has been a cause for concern; it
is not a result of the high percentages of low birth weight and infant
mortality
among the black population, because the international ranking hardly changes
when data for the white population only are used.
Whereas definitive explanations for the relatively poor position of
the United States continue to be elusive, there are sufficient hints as to
their nature to provide the basis for consideration of neglected factors:
*(1) The nature and operation of the health care system. In the United
States, in contrast to many other countries, the extent to which receipt of
services from primary care physicians vs specialists affects overall health
and survival has not been considered. While available data indicate that
specialty
care is associated with better quality of care for specific conditions in
the purview of the specialist,(15) the data on
general medical care suggest otherwise.(16) National
surveys almost all fail to obtain data on the extent to which the care
received
fulfills the criteria for primary care, so it is not possible to examine the
relationships between individual and community health characteristics and
the type of care received.
*(2) The relationship between iatrogenic effects (including both error and
nonerror adverse events) and type of care received. The results of
international
surveys document the high availability of technology in the United States.
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 United States 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 United States, high
use of diagnostic technology may be linked to the "cascade effect"(18) and
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(17)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.
How cause of death and outpatient diagnoses are coded does not facilitate
an understanding of the extent to which iatrogenic causes of ill health are
operative. Consistent use of "E" codes (external causes of injury and
poisoning)
would improve the likelihood of their recognition because these ICD
(International Classification of Diseases)
codes permit attribution of cause of effect to "Drugs, Medicinal, and
Biological
Substances Causing Adverse Effects in Therapeutic Use." More consistent use
of codes for "Complications of Surgical and Medical Care" (ICD codes 960-979
and 996-999) might improve the recognition of the
magnitude of their effect; currently, most deaths resulting from these
underlying
causes are likely to be coded according to the immediate cause of death
(such
as organ failure). The suggestions of the IOM document on mandatory
reporting of adverse effects might improve reporting in hospital settings,
but it is unlikely to affect underreporting of adverse events in
noninstitutional settings.
Only better record keeping, with documentation of all interventions and
resulting
health status (including symptoms and signs), is likely to improve the
current
ability to understand both the adverse and positive effects of health care.
*(3) The relationships among income inequality, social disadvantage, and
characteristics of health systems, including the relative contributions
of primary care and specialty care. Recent studies using
physician-to-population
ratios (as a proxy for unavailable data on actual receipt of health services
according to their type) have shown that the higher the primary care
physician-to-population
ratio in a state, the better most health outcomes are.(19)
The influence of specialty physician-to-population ratios and
of specialist-to-primary care physician ratios has not been adequately
studied, but preliminary and relatively superficial analyses suggest that
the converse may be the case. Inclusion of income inequality variables in
the analysis does not eliminate the positive effect of primary care.
Furthermore,
states that have more equitable distributions of income also are more likely
to have better primary care resource availability, thus raising questions
about the relationships among a host of social and health policy
characteristics
that determine what and how resources are available.
Recognition of the harmful effects of health care interventions, and
the likely possibility that they account for a substantial proportion of the
excess deaths in the United States compared with other comparably
industrialized
nations, sheds new light on imperatives for research and health policy.
Alternative
explanations for these realities deserve intensive exploration.
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.
MEDLINE
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.
Available at: http://www.who.int/whr/2000/en/report.htm.
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.
MEDLINE
8.
Leape L.
Unnecessary surgery.
Annu Rev Public Health.
1992;13:363-383.
MEDLINE
9.
Phillips D, Christenfeld N, Glynn L.
Increase in US medication-error deaths between 1983 and 1993.
Lancet.
1998;351:643-644.
MEDLINE
10.
Lazarou J, Pomeranz B, Corey P.
Incidence of adverse drug reactions in hospitalized patients.
JAMA.
1998;279:1200-1205.
MEDLINE
11.
Weingart SN, Wilson RM, Gibberd RW, Harrison B.
Epidemiology and medical error.
BMJ.
2000;320:774-777.
MEDLINE
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.
MEDLINE
14.
Guyer B, Hoyert D, Martin J, Ventura S, MacDorman M, Strobino D.
Annual summary of vital statistics1998.
Pediatrics.
1999;104:1229-1246.
MEDLINE
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.
MEDLINE
16.
Donahoe MT.
Comparing generalist and specialty care: discrepancies, deficiencies, and
excesses.
Arch Intern Med.
1998;158:1596-1607.
MEDLINE
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.
MEDLINE
19.
Shi L, Starfield B.
Income inequality, primary care, and health indicators.
J Fam Pract.
1999;48:275-284.
MEDLINE
© 2000 American Medical Association. All rights reserved.
http://jama.ama-assn.org/issues/v284n4/ffull/jco00061.html
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