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Figuring out the politics of patient harm Date: 12/19/14

By Michael L. Millenson

Fifteen years ago, the Institute of Medicine (IOM) issued a blockbuster report on medical error that placed patient safety permanently on the public policy map. In a made-for-the-media sound bite, “To Err is Human: Building a Safer Health System" declared that 44,000 to 98,000 Americans were dying each year from preventable medical errors in hospitals, and one million were injured. One of the victims the IOM report mentioned was Betsy Lehman, health care writer for The Boston Globe, who was killed by an accidental drug overdose in December 1994 while being treated for breast cancer.

The IOM report led network newscasts the evening of Nov. 29, 1999, and garnered page one coverage in The New York Times, The Washington Post and elsewhere the next morning. The resulting public outcry and continued media attention sparked an immediate political reaction that prompted the health care industry to undertake numerous changes.

Since then, however, patient safety has mostly faded from the public eye, as the hundred-year war over health insurance continues to occupy center stage. Even the Dec. 2 announcement by the Department of Health and Human Services that its patient safety initiative had saved 50,000 lives and $12 billion in hospital costs from 2011 to 2013 received only modest news coverage.

In an attempt to put patient safety into a context that would resonate again with political decision makers, I worked with data analyst colleagues to create a non-partisan report, The Politics of Patient Harm: Medical Error and the Safest Congressional Districts. It is the first analysis of patient safety by congressional district.

A “safe” district typically refers to a representative’s political health. We wanted to know about the physical health of constituents. Based on available information for the hospitals in each district, how many patients were likely to be killed or injured by preventable harm each year? Did living in a “red” or “blue” district, the political shorthand for Republicans and Democrats, forecast one’s medical fate?

News stories in the classic tradition are supposed to have a “who, what, why, where, when and how.” My “why” for the story was clear: Newer studies suggest that from 210,000 to 400,000 Americans are killed each year by preventable errors just in hospitals. (Outpatient data is too sparse for a reliable estimate.) Finding the “who, what, where, when and how” to fill in the story would, I thought, be a piece of cake. Grab some up-to-date indicators from Medicare, add hospital addresses and congressional district boundaries, bake-in appropriate statistical analysis, sprinkle on some commentary and serve. That’s what I told iVantage Health Analytics, and that was the basis of our modest grant from the Cautious Patient Foundation.

Unfortunately, I had vastly underestimated the difficulty of the recipe. In health care, cooking up answers to what look like simple questions can quickly get complicated. Here is some of what I learned:

What is classified as a hospital?

Because of data issues, we wanted only general, acute-care facilities. But what if a hospital delivers specialty and general care? We ultimately included any acute-care facility with 80 percent of its inpatient cases concentrated in three or fewer major diagnostic categories, according to the Medicare Provider Analysis and Review (MedPAR) files. That gave us 4,558 hospitals. Your number might vary.

Where is a hospital?

The best database of open facilities we found came from the American Hospital Association, using geocoded nine-digit ZIP code addresses and cross-referencing a map of district boundaries. However, multiple hospitals owned by one system can share a provider billing number. When that happens, a patient can’t distinguish the local hospital’s performance from that of another hospital that could be miles away. Nonetheless, we sometimes had to assign a hospital to a different district than its physical location.

What measures show whether a district is safe?

This, of course, was the central question, and the government’s Hospital Compare website won’t answer it. One reason is that more than 20 percent of hospitals are “critical access” facilities that don’t report some indicators. Meanwhile, hospitals inMaryland are reimbursed under a Medicare waiver system, so don’t collect and report billing data the way other hospitals do.

We adapted the methodology the Leapfrog Group uses and allowed for a certain amount of missing data from individual facilities to rate as many districts as possible. Even so, we couldn’t rate two districts in Texas.

When are the measures from?

To be as fair as possible, some of our measures used multiple years of data. Other times we used data from a single year. Unfortunately, the most recent data was for fiscal 2013, well over a year before our publication date.

How can you rate districts?

Yes, we had a “top 10” and “bottom 10” list, but first our data geeks calculated means, standard deviations and z-scores (don’t ask). Next, we applied a very conservative estimate of patient deaths and injuries and to our resulting three cohorts (good, fair and poor). It’s important to note that congressional districts, unlike counties or states, have a roughly equivalent population denominator based on the Supreme Court’s 1964 “one man, one vote” decision.

In the end, we found that 59 house districts were less safe than the norm and 114 districts were safer. In each congressional district ranked “poor” on safety, preventable medical errors cause an average of 553 deaths and 4,148 injuries annually; in “fair” districts, the average toll of preventable harm is 469 deaths and 3,518 injuries each year; and in “good” districts, preventable errors cause an average of 385 deaths and 2,888 injuries each year. There was no significant difference between GOP and Democratic districts.

Put differently, on average 14 more individuals die every month and 105 are injured in hospitals in districts rated “poor” on safety than in those rated “good.” Even in “good” districts, however, at least one individual dies unnecessarily every day and eight more are harmed.

There was another bottom line, as well. While we believe our report provided important information, any recipe ultimately depends upon the quality of its ingredients. Patient safety information was old, sometimes missing, frequently unusable for the general public and not adequately reliable.

Journalists can hold politicians accountable fixing that.

Michael L. Millenson (@MLMillenson) is president of Health Quality Advisors LLC and is a nationally recognized expert on making American health care better, safer and more patient-centered. He is also the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age. He holds an adjunct appointment as the Mervin Shalowitz, M.D. Visiting Scholar at Northwestern University’s Kellogg School of Management. Earlier in his career, he was a health care journalist for the Chicago Tribune.