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Journal Article > Commentary
The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality.
Chassin MR, Galvin RW. JAMA. 1998;280:1000-1005.
The National Roundtable on Health Care Quality was organized in 1996 by the Institute of Medicine and consisted of broad representation from business, education, government, the media, and health care. This 1998 consensus report articulates a definition of health care quality and indicts the US health care system for significant systematic failures to deliver high-quality care, giving several illustrative examples. The report offers a tripartite classification system—underuse, overuse, and misuse—for lapses in quality and discusses the impact of each on outcomes and health expenditures. The authors review existing efforts to improve quality, including regulation, "Continuous Quality Improvement," market forces, and payment incentives. Without prescribing a specific approach, the authors call on health care professionals to take the lead in a national health care quality improvement effort.
Tenner E. New York, NY: A.A. Knopf; 1996.
Tenner's discussions of medical and nonmedical examples provide an engaging introduction to the many ways in which new technologies can have unintended consequences. Side effects of any technology are well known and well studied. What interests Tenner, however, are ''revenge effects,'' which he defines as the exact opposite of the intended effects of a new technology. For instance, the widespread availability of computers in offices and homes was heralded as ushering in a new, paperless world. Instead, paper use sky-rocketed. From a safety perspective, numerous examples exist in which making something safer simply encouraged more reckless behavior. Health care examples often involve a safer version of a drug or procedure, which then becomes overused. At the population level, then, adverse events do not decrease and may even increase. For instance, laparoscopic cholecystectomy is a much less morbid procedure than open cholecystectomy. It is this feature of the laparoscopic procedure that resulted in a significant increase in the number of patients referred for removal of their gallbladder, to the point that morbidity and mortality at the population level did not improve as a result of this major advance in surgical technology.
Journal Article > Study
The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study.
Heyland DK, Ilan R, Jiang X, You JJ, Dodek P. BMJ Qual Saf. 2016;25:671-679.
Discordance between patient preferences for end-of-life care and documentation of their wishes is a common problem in hospitals. Such events have been described as silent misdiagnoses and may be classified as medical errors. This audit study across 16 hospitals in Canada quantified how often medical orders for life-sustaining treatments do not match patient preferences. Only 2% of patients who reported a preference for cardiopulmonary resuscitation (CPR) had CPR withheld in their medical orders; whereas, 35% of patients who wished to forgo CPR had orders to receive it in the event of an arrest. This mismatch represents a considerable source of potential overtreatment, which may result in numerous adverse downstream effects. A previous WebM&M commentary discussed tools for eliciting end-of-life preferences.
Journal Article > Study
Jørgensen KJ, Gøtzsche PC, Kalager M, Zahl P. Ann Intern Med. 2017;166:313-323.
The overuse of medical care is increasingly recognized as a patient safety issue. Overdiagnosis can result in unnecessary use of medical care, subjecting patients to greater risk of harm. For example, in the case of breast cancer, screening may detect lesions that are not clinically significant, leading to further testing and unnecessary procedures. This study examined the impact of mammography screening on a cohort of women in Denmark. Researchers found that screening was not associated with decreased incidence of advanced cancer but increased incidence of nonadvanced tumors and ductal carcinoma in situ; the rate of overdiagnosis was significant. An accompanying editorial discusses overdiagnosis in breast cancer.
Journal Article > Study
Antibiotic-resistant infection treatment costs have doubled since 2002, now exceeding $2 billion annually.
Thorpe KE, Joski P, Johnston KJ. Health Aff (Millwood). 2018;37:662-669.
Infections with antibiotic-resistant organisms are increasingly common in hospitals and ambulatory care, primarily driven by overuse of antibiotics for treatment of nonbacterial illnesses. This economic analysis found that antibiotic-resistant infections have doubled in incidence since 2002, and they add approximately $1,400 to the cost of care for each patient with an antibiotic-resistant infection. The study was performed using data from the Medical Expenditure Panel Survey, which is conducted by AHRQ. This survey does not include data on institutionalized adults, such as residents of long-term care facilities. Since antibiotic-resistant infections are common in these patients, this study may actually underestimate the total economic burden of these infections. The devastating effects of an antibiotic-resistant infection for a health care practitioner were vividly illustrated in a PSNet perspective.