Nathan Reynolds Aging Epidemiology and Services 21 May 2014 1 Introduction The adage The cure is worse than the disease has been around for the last two thousand years Quoted in some variation by ID: 311148
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Iatrogenic Diseases
Nathan ReynoldsAging: Epidemiology and Services21 May 2014
1Slide2
Introduction
The adage “The cure is worse than the disease” has been around for the last two thousand yearsQuoted in some variation byPlutarch (46 – 120 CE)
Pubilius
Syrus (1st century CE)Sir Francis Bacon (1561 – 1626 CE) Although in today’s context, this is a bit extreme, it highlights that medical care is inherently risky and offers a double-edged sword of benefits and side-effects or harm
2Slide3
Introduction
Iatrogenic DiseasesFrom Greek Iatros
, meaning healer or physician, and
Genesis,
meaning birth or originAn unintended adverse patient outcome due to any therapeutic, diagnostic and prophylactic intervention not considered natural in the course of a disease3Slide4
Epidemiology
Much of the evidence on iatrogenic disease comes from hospital settings in industrialized countries
Less is known about the frequency of patient safety incidents and prevention of harm in the primary care settings of low- and middle-income countries
As primary-care clinics are the initial point of entry into the healthcare system, it is urgent to study the frequency and preventability of patient safety incidents
Cresswell KM, Panesar
SS,
Salvilla
SA, Carson-Stevens A,
Larizoitia
I, Donaldson LJ, et al. Global Research Priorities to Better Understand the Burden of Iatrogenic Harm in Primary Care: An International Delphi Exercise.
PLOSMedicine. 2013;10(11):1-6.
4Slide5
Epidemiology
In the United States, Iatrogenic Diseases represent the 3rd
leading cause of death behind heart disease and cancer
Breakdown:
12,000 deaths/year from unnecessary surgery 7,000 deaths/year from medication errors in hospitals20,000 deaths/year from other hospital errors80,000 deaths/year from nosocomial infections in hospitals106,000 deaths/year from non-error, adverse effects of medicationsTotal: 225,000
deaths/year
Starfield
B. Is US Health Really the Best in the World? JAMA. 2000; 284(4):483-485
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Epi Cont’d
Explaining the limitations of Starfield’s
estimate
Most of the data is derived from studies in hospital patients
The estimates are only for deaths and do not include the adverse effects of disability or discomfort The estimate of death due to medical error is lower than the value the Institute of MedicineWhen the numbers are adjusted, the estimate ranges from 230,000 to 284,000 deaths/year
Grisanti
R. Iatrogenic Disease The 3
rd
most fatal disease
in the USA. http://www.americanchiropractic.net/medical_statistics/Iatrogenic%20Disease.pdf
7Slide8
Costs
One analysis indicates that between 4% and 14% of consecutive patients experience adverse effects in outpatient settings resulting in:
116 million extra physician visits per annum
77 million extra prescriptions per annum
17 million emergency department visits per annum8 million hospitalizations per annumAt a cost of $77 billion USD, or the aggregate cost of care of patients with diabetes
Weingart
SN, Wilson RM,
Gibberd
RW, Harrison B. Epidemiology and Medical Error. BMJ. 2000;320:774-777.
8Slide9
Risk Factors
Polypharmacy represents the most ubiquitous risk for iatrogenic diseasesIncreased number of medications taken daily increase the risk of drug-drug or drug-disease interactions
Other Adverse Drug Effects (ADEs) including allergic reactions or misprescribed drugs
Treatment of Multiple Chronic Diseases
Treatment of one disease will exacerbate other conditionsi.e. Treatment of arthritis with NSAIDs may exacerbate kidney failure, heart failure, coronary artery disease or chronic gastritis
Pacala
JT. Prevention of iatrogenic complications in the elderly. Geriatrics. 2009.
http://www.merckmanuals.com/professional/sec23/ch342/ch342e.html
.
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Risk Factors Cont’d
Multiple PhysiciansCan lead to uncoordinated care and/or unnecessary polypharmacy
Therapeutic regimen changed without input of patient’s other physicians
Hospital/Nursing Home Stays
Psychological effects Nosocomial Infections Pressure or Bed Sores
Permpogkosol
S. Iatrogenic disease in the elderly: risk factors, consequences, and prevention. Clinical Interventions in Aging. 2011;6:77-82.
10Slide11
Number of adverse events, preventable adverse events, and number resulting in permanent disability by age.
Weingart
N S et al. BMJ 2000;320:774-777
©2000 by British Medical Journal Publishing GroupSlide12
Age as a Risk Factor
12Older age groups are at higher risk because of:
Diminished reserve and ability to respond to stress
Decline in cardiac reserve
Diminished immune response, increased chance of infectionExaggerated effects of medications Atypical presentation of disease stemming from misinterpretation, missed diagnosisLeads to treatment delaySlide13
Age as a Risk Factor, Cont’d
13Inadequate geriatric training of healthcare providers
i.e.,
No national geriatric certification requirements
No national scopes and standards for careNo JCAHO requirements for staff competence in care of older adults Slide14
14
Suggested that at least 50% of iatrogenic disease are preventable Including >70% of events in ICUs
The first step is to identify patients who are at greatest risk
Polypharmacy
Multiple physiciansMultiple chronic diseasesExtended hospital staysMercier E, Giraudeau
B,
Giniès
G,
Perrotin
D,
Dequin PF.
Iatrogenic
events contributing to ICU admission: a prospective study
.
Intensive
Care Med. 2010 Jun; 36(6):1033-7.
Prevention
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Prevention, Cont’d
Merck Manual suggests the following:Care Management: Care managers facilitate communication among health care practitioners, ensure that needed services are provided, and prevent duplication of services. They could be employed by physician groups, health plans, or governmental organizations
Pharmacist Consultation
: A pharmacist can help prevent potential complications caused by polypharmacy and inappropriate drug use
Acute Care for the Elderly (ACE) units: Hospital wards with protocols to ensure that elderly patients are thoroughly evaluated for potential iatrogenic problems before those problems occur in order for such problems to be appropriately managed15Slide16
Prevention, Cont’d
Merck Manual suggests the following:Geriatric Interdisciplinary Team: This team evaluates all of the patient’s needs, develops a coordinated care plan, and manages care. *Resource-intensive and should be limited to patients with complex cases
Advanced Directives:
Designation of a proxy to make medical decisions and advanced directives on care. This can help to prevent unwanted medical treatment who cannot speak for themselves
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Prevention, Cont’d
More rigorous physician and nurse training in geriatric careBoth in curriculum at school and as continuing education at hospitals
Accreditation by either JCI or JCAHO
specifically for
geriatric care Proposal for the United States- a stronger emphasis on primary care physicians, over specialists, in an effort to prevent communication issues between multiple physiciansImpacts on patient care as a result of the PPACA (ObamaCare), including a stronger emphasis of primary care, remains to be seen
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Conclusions
Due to the demographic transition, iatrogenic diseases will continue to be at the forefront of health care concernsMore elderly patients with mentioned risk factors are utilizing the health care system Higher risk of
iatrogenesis
There are both policy changes and hospital/clinical practices that can be modified to improve patient safety and health outcomes, but they require resources, compliance, and motivation by the hospital administration and clinicians to integrate new policies into the daily operation of the institution 18