a follow-up on the primary care initiative in UK

Bill Galanter just sent me the link to the UK report on primary care from the House of Commons Health Committee (which i could not find when sending out the initial blog). will attach a copy of the report as well as the link (http://www.publications.parliament.uk/pa/cm201516/cmselect/cmhealth/408/408.pdf ). Basic issues addressed in the report:

--improve access to primary care by extending hours of service, reaching out to those currently disenfranchised by the existing model of care

--improve record keeping and access to medical records as a means to improve patient safety, with patient consent for more general access to records

--facilitate phone and IT access for patients and for consultations

--quality improvement initiatives: Care Quality Commission inspection of primary care practices, helping practices improve

--“Ten-minute appointments do not allow adequate time for safe practice or to address whole person care. Relentless time pressure from short appointments tends to restrict patients to discussing only one problem with their GP and clinicians to working in a reactive rather than proactive manner. Given the increasing complexity of the long term conditions that are managed in primary care, allowing time to provide safe and holistic care must be a priority. We agree with the Primary Care Workforce Commission that reshaping primary care to give patients sufficient time to discuss their conditions with health professionals should be a central aim of the new models of care.”

--develop and extend the use of team-based care, including using “physician associates”

--increase access to consultant psychiatrists. increase communication with specialists overall by email and messaging

--continued vigilance at national and local level to make sure that conflicts of interest are not influencing decisions

--significantly increase the number of primary care doctors by attracting more doctors into the field. look carefully at why doctors quit.

--promote primary care in medical schools, including expanding the criteria for med school admissions (eg, including commitment to providing care to a community, not just purely scientific qualifications), increasing teaching of general practice, and stress that the career is as intellectually rewarding as any specialization

--use financial incentives/loan repayment to help place MDs and nurses in areas that historically have had trouble attracting them

--many similar approaches as above for attracting and retention of nurses, physician associates, physiotherapists, pharmacists in primary care

--look at other funding mechanisms, including capitated payment systems within primary care federations

--a larger proportion of the health care money should go to primary care

--make sure that financial mechanisms reinforce primary care, instead of diverting patients inappropriately to secondary care

so, pretty impressive in many ways. not only does it reinforce primary care as the crux of the health care system, but it suggests several specific reforms to enable that. unfortunately, in the US we not only do not have a coherent and integrated system of care with universal access, but we have a system dominated by hospitals and procedure-oriented specialists. even the move to capitation seems to situate hospitals and not primary care at its center. and the decision-makers for our reimbursement system is dominated by those who make lots of money from procedures (and, as i have said before, injecting a patient for carpal tunnel syndrome or painful joints takes me a few minutes and is not very complex. taking care of my patient with uncontrolled hypertension, diabetes, etc, who is in an untenable social situation, and is depressed, is really intellectually and emotionally difficult and very time-consuming). but i think the kernel of the current UK initiatives is central to a major reorientation of our health care system (and extending the system to one of universal access is certainly another essential aspect).

geoff

From: Galanter, Bill [mailto:BillG@UIC.EDU]
Sent: Thursday, May 12, 2016 4:59 PM
To: Geoff A. Modest, M.D.
Subject: RE: medical errors, and a plea for primary care

Primary Care report.

Thanks for the updates.

From: Geoff A. Modest, M.D. [mailto:GModest@uphams.org]
Sent: Thursday, May 12, 2016 6:47 AM
To: Geoff A. Modest, M.D.
Subject: medical errors, and a plea for primary care

 There was a recent brief article looking at the approximate rate of medical errors leading to death, and suggesting that this was the 3rd leading cause of death in the US (see medical errors bmj2016 in dropbox, or doi: 10.1136/bmj.i2139). details:

--a 1999 Institute of Medicine report, based on the 1984 Harvard Medical Practice Study and the 1992 Utah and Colorado Study, suggested that of the 180,000 reported iatrogenic deaths, 51% were preventable, though the lead Harvard researcher suggested that the number was closer to 78% (ie 140,400 preventable deaths). this number was based on a record review of a  population-based study of New York Hospitals reported in 1993. overall there was a 4% incidence of adverse events reported in the hospitalized patients.

--a 2004 report from the Agency for Healthcare Quality and Research Patient Safety Indicators for the Medicare population estimated 195,000 deaths from medical errors per year (data from 2000-2002). this study found that of 37,000,000 admissions, there was an adverse event rate of 3.1%, a lethal adverse event rate of 0.7%, 389576 preventable deaths over these years, which they extrapolated to 2013​​ to be 251,454 preventable lethal adverse events.

--the US Dept of Health and Human Services/Office of Inspector General examined health records of hospital inpatients in 2008, finding 180,000 deaths/year from medical errors in those on Medicare. this study found that of 838 admissions, there was an adverse event rate of 13.5%, a lethal adverse event rate of 1.4%, a 44% rate of preventable deaths, leading to 12 deaths, which they extrapolated to 2013 to be 219,579 preventable lethal adverse events​

--a 2004 study of 3 tertiary care hospitals (2 community-based teaching hospitals, both urban with one in the Mid-west and one Northeast, and one academic hospital in the West)  finding that of 795 admissions, there was an adverse event rate of 33.2% (!!!),  a lethal adverse event rate of 1.1%, 100% felt to be preventable, leading to 9 deaths, which they extrapolated to 2013 to be 400,201 preventable lethal adverse events

--a 2002-7 study of 10 hospitals in North Carolina​, finding that of 2341 admissions, there was an adverse event rate of 18.1%, a lethal adverse event rate of 0.6%, 63% felt to be preventable, leading to 14 deaths, which they extrapolated to 2013 to be 134,581 preventable lethal adverse events

--the summary findings were the same as those of the AHRQ/Medicare study, since its 37M admissions so dwarfs the other studies in the weighted average. (so, estimated number of preventable deaths was set at 251,454 for 2013)

--and, none of these studies included deaths at home, or in nursing homes, or in an ambulatory setting (which is an issue, both in terms of hospitalized patients who may have been discharged from the hospital but may have died relatively shortly thereafter from a hospital-related error, and because some patients undoubtedly die because of errors in medical care in the non-hospital setting itself).

so, there are certainly several issues here:

--the quality of the data: the list of causes of death, per the CDC, is based on ICD coding, and there are no codes for diagnostic errors, poor judgment, inadequate skills, or, in general, either human or systems errors that could lead to death. and, accurate numbers still assume that the people or the institution involved is willing to acknowledge that a preventable cause of death occurred.

--it is pretty striking that the number of adverse events was so variable (why was the Medicare one in the 3% range, yet up to 33% in the 3 tertiary care hospitals? is it how adverse events are classified? is it that Medicare just wasn't looking hard enough?), but still, finding up to 1% of admissions were associated with preventable deaths is shocking....

--there are many methodological concerns with the data in this report:

    --how accurate are the data collected (and how do they define a death as preventable )?

    --how extrapolatable are the data from a survey of 3 or 10 hospitals, or even the Medicare data, to the general population, in teaching and nonteaching hospitals, in small and large hospitals, in urban and rural hospitals, in hospitals with a slew of specialists and not, etc

    --how extrapolatable is the preventable death rate from 2002 or 2008 to 2013? lots has changed. part is that the degree of illness of admitted patients may have changed. or the intensity of testing. or doing higher risk procedures. and the extrapolation of preventable deaths to 2013 as done in the above study is based only on the number of admissions in 2013 vs the number in the year studied

--but, the bottom line is that there are a huge number of potentially preventable deaths, that the number is probably in the general ballpark of what they report, and that as such a huge issue, we should be devoting large amounts of resources to deal with this (ie, one might think that prioritizing this issue makes sense, perhaps over developing/using another orphan drug for a rare disease, or devoting large amounts of resources to providing very expensive care to a terminal cancer patient where the benefit is on the order of a few months of additional life or less)

--one very related issue to me is the remarkably backward nature of our health care system. it seems to me that the primary way to avoid preventable hospital-related deaths is to prevent hospitalization. which for many of my patients in the 80-100 year old range, means preventing their going to the ER unless really necessary. which means redesigning the orientation and reimbursement of the health care system to value primary care, move away from the 10-20 minute appointments (which, in the era of electronic medical records, translates to 5-10 minutes actually spent with the patient during which time we take care of their diabetes, hypertension, depression, domestic violence/other social issues, and their preventive care issues, etc). and giving us the time and associated reimbursement to allow us to really take care of the patients' problems, be accessible to avoid unnecessary ER visits and thereby decrease unnecessary hospitalizations. my experience is that when one of my frail patients goes to the ER for a likely minor problem, they are usually admitted (and i do not blame the ER physicians, since they see a frail person, do not know them, are not sure they will get outpatient followup, and feel that it is better to be safe than sorry. though i almost never get a phone call to see if we can see the person the next morning. and the reality is that about 50% of my elderly patients admitted do not need admission, they often stay longer than they should, they decondition after 2 days, then they go to a rehab facility to recondition......and, in many cases, they become delirious and are put on unnecessary medications which lead to significant morbidity. 

--of note, the April 30 issue of Lancet had a brief article and relevant editorial supporting a fundamental reworking of primary care for the NHS in the UK, with a large program to increase primary care recruitment, support primary care, streamline bureaucracy and improve reimbursement (see https://www.england.nhs.uk/ourwork/gpfv/ for a 5 year plan). there is also a report Primary Care by the House of Commons Health Committee "which emphasizes the need for increased funding of general practice to improve access to care and services for patients, such as extending the traditional 10 minute appointment time" -- though i was unable to locate that report. And this is in the UK, which already has a universal, reasonably coherent/connected, accessible system of care (ie, already much beyond us)...