Iatrogenic Diseases

N AT H A N R E Y N O L D S A G I N G : E P I D E M I O L O G Y A N D S E RV I C E S 2 1 M AY 2 0 1 4 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  Plutarch (46 – 120 CE)  Pubilius Syrus (1 st 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 2

Introduction Iatrogenic Diseases

• From Greek

Iatros

, meaning healer or physician, and

Genesis,

origin meaning birth or • An unintended adverse patient outcome due to any therapeutic, diagnostic and prophylactic intervention not considered natural in the course of a disease 3

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. 4

Epidemiology

In the United States, Iatrogenic Diseases represent the

3 rd

heart disease and cancer leading cause of death behind Breakdown: ◦ 12,000 deaths/year from unnecessary surgery ◦ ◦ 7,000 deaths/year from medication errors in hospitals 20,000 deaths/year from other hospital errors ◦ ◦ 80,000 deaths/year from nosocomial infections in hospitals 106,000 deaths/year from non-error, adverse effects of medications Total:

225,000

deaths/year Starfield B. Is US Health Really the Best in the World? JAMA. 2000; 284(4):483-485 5

TOP 5 LEADING CAUSES OF DEATH IN THE UNITED STATES, 2011 (SOURCE: CDC)

597 689 547 743

Cardiovascular Disease Cancer

225 000 138 080 129 476

Iatrogenic Disease* Chronic Lower Respiratory Diseases Cerebrovascular Diseases 6

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 Medicine When 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

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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 annum  8 million hospitalizations per annum At 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. 8

Risk Factors

Polypharmacy

represents the most ubiquitous risk for iatrogenic diseases  Increased 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 conditions  i.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 Physicians

 Can 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. 10

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 Group

Age as a Risk Factor

Older 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 infection  Exaggerated effects of medications  Atypical presentation of disease stemming from misinterpretation, missed diagnosis  Leads to treatment delay 12

Age as a Risk Factor, Cont’d

Inadequate geriatric training of healthcare providers i.e.,  No national geriatric certification requirements  No national scopes and standards for care  No JCAHO requirements for staff competence in care of older adults 13

Prevention

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 physicians  Multiple chronic diseases  Extended hospital stays

Mercier 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.

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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 managed 15

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 16

Prevention, Cont’d

More rigorous physician and nurse training in geriatric care ◦ Both 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 physicians ◦ Impacts on patient care as a result of the PPACA (ObamaCare), including a stronger emphasis of primary care, remains to be seen 17

Conclusions

Due to the demographic transition, iatrogenic diseases will continue to be at the forefront of health care concerns ◦ More 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