Iatrogenic Disease

Report
Iatrogenic Diseases
N AT H A N RE Y N O L D S
A G I N G : E P I D E MIO LOG Y A N D S ERV I CES
2 1 MAY 2 0 1 4
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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 (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
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Introduction
Iatrogenic Diseases
•From Greek Iatros, meaning healer or physician, and Genesis, meaning birth or
origin
•An unintended adverse patient outcome due to any therapeutic, diagnostic and
prophylactic intervention not considered natural in the course of a disease
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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.
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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 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
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TOP 5 LEADING CAUSES OF DEATH IN THE UNITED STATES,
2011
(SOURCE: CDC)
597,689
547,743
225,000
138,080
Cardiovascular
Disease
Cancer
Iatrogenic
Disease*
Chronic Lower
Respiratory
Diseases
129,476
Cerebrovascular
Diseases
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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
Medicine
When the numbers are adjusted, the estimate ranges from 230,000 to 284,000
deaths/year
Grisanti R. Iatrogenic Disease The 3rd 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.
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Risk Factors
Polypharmacy represents the most ubiquitous risk for iatrogenic diseases
 Increased number of medications taken daily increase the risk of drug-drug or drugdisease 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.
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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
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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
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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
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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 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
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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
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