AMA Report

May 7, 2001

Journal American Medical Association Vol 284 July 26, 2000

This article in the Journal of the American Medical Association (JAMA)

is the best article I have ever seen written in the published literature

documenting the tragedy of the traditional medical paradigm.

This information is a followup of the Institute of Medicine report which

hit the papers in December of last year, but the data was hard to

reference as it was not in peer-reviewed journal. Now it is published in

JAMA which is the most widely circulated medical periodical in the

world.

The author is Dr. Barbara Starfield of the Johns Hopkins School of

Hygiene and Public Health and she desribes how the US health care system

may contribute to poor health.

ALL THESE ARE DEATHS PER YEAR:

12,000 -----unnecessary surgery 8

7,000 -----medication errors in

hospitals 9

20,000 ----other errors in hospitals 10

80,000 ----infections in hospitals

10

106,000 ---non-error, negative

effects of drugs 2

These total to 250,000 deaths per year from iatrogenic causes!!

What does the word iatrogenic mean? This term is defined as induced in a

patient by a physician's activity, manner, or therapy. Used especially

of a complication of treatment.

Dr. Starfield offers several warnings in interpreting these numbers:

First, most of the data are derived

from studies in hospitalized patients. Second, these estimates

are for deaths only and do not include negative effects that

are associated with disability or discomfort. Third, the

estimates of death due to error are lower than those in the IOM report.1

If the higher estimates are used, the deaths due to iatrogenic causes

would range from 230,000 to 284,000. In any case, 225,000 deaths per

year constitutes the third leading cause of death in the United States,

after deaths from heart disease and cancer. Even if these figures are

overestimated, there is a wide margin between these numbers of deaths

and the next leading cause of death (cerebrovascular disease).

Another analysis concluded that between 4% and 18% of consecutive

patients experience negative effects in outpatient settings,with:

116 million extra physician visits

77 million extra prescriptions

17 million emergency department visits

8 million hospitalizations

3 million long-term admissions

199,000 additional deaths

$77 billion in extra costs

The high cost of the health care system is considered to be a deficit,

but seems to be tolerated under the assumption that better health

results from more expensive care.

However, evidence from a few studies indicates that as many as 20% to

30% of patients receive inappropriate care.

An estimated 44,000 to 98,000 among them die each year as a result of

medical errors.2

This might be tolerated if it resulted in better health, but does it? Of

13 countries in a recent comparison,3,4 the United States ranks an

average of 12th (second from the bottom) for 16 available health

indicators. More specifically, the ranking of the US on several

indicators was:

13th (last) for low-birth-weight

percentages 13th for neonatal mortality and infant mortality

overall 14 11th for postneonatal mortality

13th for years of potential life

lost (excluding external causes) 11th for life expectancy at 1

year for females, 12th for males 10th for life expectancy at 15

years for females, 12th for males 10th for life expectancy at 40

years for females, 9th for males 7th for life expectancy at 65

years for females, 7th for males 3rd for life expectancy at 80

years for females, 3rd for males 10th for age-adjusted mortality

The poor performance of the US was recently confirmed by a World Health

Organization study, which used different data and ranked the United

States as 15th among 25 industrialized countries.

There is a perception that the American public " behaves badly " by

smoking, drinking, and perpetrating violence. " However the data does not

support this assertion.

The proportion of females who smoke

ranges from 14% in Japan to 41% in Denmark; in the United States, it is

24% (fifth best). For males, the range is

from 26% in Sweden to 61% in Japan;

it is 28% in the United States (third best).

The US ranks fifth best for

alcoholic beverage consumption. The US has relatively low

consumption of animal fats (fifth lowest in men aged 55-64

years in 20 industrialized countries) and the third lowest mean

cholesterol concentrations among men aged 50 to 70 years among 13

industrialized

countries.

These estimates of death due to error are lower than those in a recent

Institutes of Medicine report, and if the higher estimates are used, the

deaths due to iatrogenic causes would range from 230,000 to 284,000.

Even at the lower estimate of 225,000 deaths per year, this constitutes

the third leading cause of death in the US, following heart disease and

cancer.

Lack of technology is certainly not a contributing factor to the US's

low ranking.

Among 29 countries, the United

States is second only to Japan in the availability of magnetic resonance

imaging units and computed tomography

scanners per million population. 17

Japan, however, ranks highest on

health, whereas the US ranks among the lowest. It is possible

that the high use of technology in Japan is limited to diagnostic

technology not matched by high rates of treatment, whereas in the US,

high use of diagnostic technology may be linked to more

treatment. Supporting this possibility are data showing that the

number of employees per bed

(full-time equivalents) in the United States is highest among the

countries ranked, whereas they are very low in Japan, far lower than

can be accounted

for by the common practice of having family members rather than

hospital staff provide the amenities of hospital care.

Journal American Medical Association Vol 284 July 26, 2000

COMMENT: Folks, this is what they call a " Landmark Article " . Only

several ones like this are

published every year. One of the major reasons it is so huge as that it

is published in JAMA which is the largest and one of the most respected

medical journals in the entire world. I did find it most curious that

the best wire service in the world, Reuter's, did not pick up this

article. I have no idea why they let it slip by.

I would encourage you to bookmark this article and review it several

times so you can use the statistics to counter the arguments of your

friends and relatives who are so enthralled with the traditional medical

paradigm. These statistics prove very clearly that the system is just

not working. It is broken and is in desperate need of repair.

I was previously fond of saying that drugs are the fourth leading cause

of death in this country. However, this article makes it quite clear

that the more powerful number is that doctors are the third leading

cause of death in this country killing nearly a quarter million people a

year. The only more common causes are cancer and heart disease. This

statistic is likely to be seriously underestimated as much of the coding

only describes the cause of organ failure and does not address

iatrogenic causes at all.

Japan seems to have benefited from recognizing that technology is

wonderful, but just because you diagnose something with it, one should

not be committed to undergoing treatment in the traditional paradigm.

Their health statistics reflect this aspect of their philosophy as much

of their treatment is not treatment at all, but loving care rendered in

the home.

Care, not treatment, is the answer. Drugs, surgery and hospitals are

rarely the answer to chronic health problems. Facilitating the God-given

healing capacity that all of us have is the key. Improving the diet,

exercise, and lifestyle are basic. Effective interventions for the

underlying emotional and spiritual wounding behind most chronic illness

are also important clues to maximizing health and reducing disease.

Related Articles: Author/Article Information

Author Affiliation: Department of Health Policy and Management, Johns

Hopkins School of Hygiene and Public Health, Baltimore, Md.

Corresponding Author and Reprints: Barbara Starfield, MD, MPH,

Department of Health Policy and Management, Johns Hopkins School of

Hygiene and Public Health, 624 N

Broadway, Room 452, Baltimore, MD 21205-1996 (e-mail:

bstarfie).

REFERENCES

1. Schuster M, McGlynn E, Brook R. How good is the quality of health

care in the United States?

Milbank Q. 1998;76:517-563.

2. Kohn L, ed, Corrigan J, ed, Donaldson M, ed. To Err Is Human:

Building a Safer Health System. Washington, DC: National Academy Press;

1999.

3. Starfield B. Primary Care: Balancing Health Needs, Services, and

Technology. New York, NY: Oxford University Press; 1998.

4. World Health Report 2000. Available at:

http://www.who.int/whr/2000/en/report.htm. Accessed June 28, 2000.

5. Kunst A. Cross-national Comparisons of Socioeconomic Differences in

Mortality. Rotterdam, the Netherlands: Erasmus University; 1997.

6. Law M, Wald N. Why heart disease mortality is low in France: the time

lag explanation. BMJ. 1999;313:1471-1480.

7. Starfield B. Evaluating the State Children's Health Insurance

Program: critical considerations.

Annu Rev Public Health. 2000;21:569-585.

8. Leape L.Unecessarsary surgery. Annu Rev Public Health.

1992;13:363-383.

9. Phillips D, Christenfeld N, Glynn L. Increase in US medication-error

deaths between 1983 and 1993. Lancet. 1998;351:643-644.

10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions

in hospitalized patients. JAMA. 1998;279:1200-1205.

11. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology and

medical error. BMJ. 2000;320:774-777.

12. Wilkinson R. Unhealthy Societies: The Afflictions of Inequality.

London, England: Routledge; 1996.

13. Evans R, Roos N. What is right about the Canadian health system?

Milbank Q. 1999;77:393-399.

14. Guyer B, Hoyert D, Martin J, Ventura S, MacDorman M, Strobino D.

Annual summary of vital statistics1998. Pediatrics. 1999;104:1229-1246.

15. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and

outcomes of care for generalists and specialists. J Gen Intern Med.

1999;14:499-511.

16. Donahoe MT. Comparing generalist and specialty care: discrepancies,

deficiencies, and excesses. Arch Intern Med. 1998;158:1596-1607.

17. Anderson G, Poullier J-P. Health Spending, Access, and Outcomes:

Trends in Industrialized Countries. New York, NY: The Commonwealth Fund;

1999.

18. Mold J, Stein H. The cascade effect in the clinical care of

patients. N Engl J Med. 1986;314:512-514.

19. Shi L, Starfield B. Income inequality, primary care, and health

indicators. J Fam Pract. 1999;48:275-284.

May 11, 2001

Very sobering Pearl, and thanks for the stats.

Ian "Doc" Shillington N.D.505-772-5889Dr.IanShillington

This article in the Journal of the American Medical Association (JAMA)is the best article I have ever seen written in the published literaturedocumenting the tragedy of the traditional medical paradigm. This information is a followup of the Institute of Medicine report whichhit the papers in December of last year, but the data was hard toreference as it was not in peer-reviewed journal. Now it is published inJAMA which is the most widely circulated medical periodical in theworld. The author is Dr. Barbara Starfield of the Johns Hopkins School ofHygiene and Public Health and she desribes how the US health care systemmay contribute to poor health. ALL THESE ARE DEATHS PER YEAR: 12,000 -----unnecessary surgery 8 7,000 -----medication errors inhospitals 9 20,000 ----other errors in hospitals 10 80,000 ----infections in hospitals10 106,000 ---non-error, negativeeffects of drugs 2 These total to 250,000 deaths per year from iatrogenic causes!! What does the word iatrogenic mean? This term is defined as induced in apatient by a physician's activity, manner, or therapy. Used especiallyof a complication of treatment. Dr. Starfield offers several warnings in interpreting these numbers: First, most of the data are derivedfrom studies in hospitalized patients. Second, these estimatesare for deaths only and do not include negative effects that are associated with disability or discomfort. Third, theestimates of death due to error are lower than those in the IOM report.1 If the higher estimates are used, the deaths due to iatrogenic causeswould range from 230,000 to 284,000. In any case, 225,000 deaths peryear constitutes the third leading cause of death in the United States,after deaths from heart disease and cancer. Even if these figures areoverestimated, there is a wide margin between these numbers of deathsand the next leading cause of death (cerebrovascular disease). Another analysis concluded that between 4% and 18% of consecutivepatients experience negative effects in outpatient settings,with: 116 million extra physician visits 77 million extra prescriptions 17 million emergency department visits 8 million hospitalizations 3 million long-term admissions 199,000 additional deaths $77 billion in extra costs The high cost of the health care system is considered to be a deficit,but seems to be tolerated under the assumption that better healthresults from more expensive care. However, evidence from a few studies indicates that as many as 20% to30% of patients receive inappropriate care. An estimated 44,000 to 98,000 among them die each year as a result ofmedical errors.2 This might be tolerated if it resulted in better health, but does it? Of13 countries in a recent comparison,3,4 the United States ranks anaverage of 12th (second from the bottom) for 16 available healthindicators. More specifically, the ranking of the US on severalindicators was: 13th (last) for low-birth-weightpercentages 13th for neonatal mortality and infant mortalityoverall 14 11th for postneonatal mortality 13th for years of potential lifelost (excluding external causes) 11th for life expectancy at 1year for females, 12th for males 10th for life expectancy at 15years for females, 12th for males 10th for life expectancy at 40years for females, 9th for males 7th for life expectancy at 65years for females, 7th for males 3rd for life expectancy at 80years for females, 3rd for males 10th for age-adjusted mortality The poor performance of the US was recently confirmed by a World HealthOrganization study, which used different data and ranked the UnitedStates as 15th among 25 industrialized countries. There is a perception that the American public "behaves badly" bysmoking, drinking, and perpetrating violence." However the data does notsupport this assertion. The proportion of females who smokeranges from 14% in Japan to 41% in Denmark; in the United States, it is24% (fifth best). For males, the range is from 26% in Sweden to 61% in Japan;it is 28% in the United States (third best). The US ranks fifth best foralcoholic beverage consumption. The US has relatively lowconsumption of animal fats (fifth lowest in men aged 55-64 years in 20 industrialized countries) and the third lowest mean cholesterol concentrations among men aged 50 to 70 years among 13industrialized countries. These estimates of death due to error are lower than those in a recentInstitutes of Medicine report, and if the higher estimates are used, thedeaths due to iatrogenic causes would range from 230,000 to 284,000. Even at the lower estimate of 225,000 deaths per year, this constitutesthe third leading cause of death in the US, following heart disease andcancer. Lack of technology is certainly not a contributing factor to the US'slow ranking. Among 29 countries, the UnitedStates is second only to Japan in the availability of magnetic resonanceimaging units and computed tomography scanners per million population. 17 Japan, however, ranks highest onhealth, whereas the US ranks among the lowest. It is possiblethat the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the US, high use of diagnostic technology may be linked to moretreatment. Supporting this possibility are data showing that thenumber of employees per bed (full-time equivalents) in the United States is highest among the countries ranked, whereas they are very low in Japan, far lower thancan be accounted for by the common practice of having family members rather thanhospital staff provide the amenities of hospital care. Journal American Medical Association Vol 284 July 26, 2000 COMMENT: Folks, this is what they call a "Landmark Article". Onlyseveral ones like this are published every year. One of the major reasons it is so huge as that itis published in JAMA which is the largest and one of the most respectedmedical journals in the entire world. I did find it most curious thatthe best wire service in the world, Reuter's, did not pick up thisarticle. I have no idea why they let it slip by. I would encourage you to bookmark this article and review it severaltimes so you can use the statistics to counter the arguments of yourfriends and relatives who are so enthralled with the traditional medicalparadigm. These statistics prove very clearly that the system is justnot working. It is broken and is in desperate need of repair. I was previously fond of saying that drugs are the fourth leading causeof death in this country. However, this article makes it quite clearthat the more powerful number is that doctors are the third leadingcause of death in this country killing nearly a quarter million people ayear. The only more common causes are cancer and heart disease. Thisstatistic is likely to be seriously underestimated as much of the codingonly describes the cause of organ failure and does not addressiatrogenic causes at all. Japan seems to have benefited from recognizing that technology iswonderful, but just because you diagnose something with it, one shouldnot be committed to undergoing treatment in the traditional paradigm.Their health statistics reflect this aspect of their philosophy as muchof their treatment is not treatment at all, but loving care rendered inthe home. Care, not treatment, is the answer. Drugs, surgery and hospitals arerarely the answer to chronic health problems. Facilitating the God-givenhealing capacity that all of us have is the key. Improving the diet,exercise, and lifestyle are basic. Effective interventions for theunderlying emotional and spiritual wounding behind most chronic illnessare also important clues to maximizing health and reducing disease. Related Articles: Author/Article Information Author Affiliation: Department of Health Policy and Management, JohnsHopkins School of Hygiene and Public Health, Baltimore, Md.Corresponding Author and Reprints: Barbara Starfield, MD, MPH,Department of Health Policy and Management, Johns Hopkins School ofHygiene and Public Health, 624 N Broadway, Room 452, Baltimore, MD 21205-1996 (e-mail:bstarfie). REFERENCES 1. Schuster M, McGlynn E, Brook R. How good is the quality of healthcare in the United States? Milbank Q. 1998;76:517-563. 2. Kohn L, ed, Corrigan J, ed, Donaldson M, ed. To Err Is Human:Building a Safer Health System. Washington, DC: National Academy Press;1999. 3. Starfield B. Primary Care: Balancing Health Needs, Services, andTechnology. New York, NY: Oxford University Press; 1998. 4. World Health Report 2000. Available at:http://www.who.int/whr/2000/en/report.htm. Accessed June 28, 2000. 5. Kunst A. Cross-national Comparisons of Socioeconomic Differences inMortality. Rotterdam, the Netherlands: Erasmus University; 1997. 6. Law M, Wald N. Why heart disease mortality is low in France: the timelag explanation. BMJ. 1999;313:1471-1480. 7. Starfield B. Evaluating the State Children's Health InsuranceProgram: critical considerations. Annu Rev Public Health. 2000;21:569-585. 8. Leape L.Unecessarsary surgery. Annu Rev Public Health.1992;13:363-383. 9. Phillips D, Christenfeld N, Glynn L. Increase in US medication-errordeaths between 1983 and 1993. Lancet. 1998;351:643-644. 10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactionsin hospitalized patients. JAMA. 1998;279:1200-1205. 11. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology andmedical error. BMJ. 2000;320:774-777. 12. Wilkinson R. Unhealthy Societies: The Afflictions of Inequality.London, England: Routledge; 1996. 13. Evans R, Roos N. What is right about the Canadian health system?Milbank Q. 1999;77:393-399. 14. Guyer B, Hoyert D, Martin J, Ventura S, MacDorman M, Strobino D.Annual summary of vital statistics1998. Pediatrics. 1999;104:1229-1246. 15. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, andoutcomes of care for generalists and specialists. J Gen Intern Med.1999;14:499-511. 16. Donahoe MT. Comparing generalist and specialty care: discrepancies,deficiencies, and excesses. Arch Intern Med. 1998;158:1596-1607. 17. Anderson G, Poullier J-P. Health Spending, Access, and Outcomes:Trends in Industrialized Countries. New York, NY: The Commonwealth Fund;1999. 18. Mold J, Stein H. The cascade effect in the clinical care ofpatients. N Engl J Med. 1986;314:512-514. 19. Shi L, Starfield B. Income inequality, primary care, and healthindicators. J Fam Pract. 1999;48:275-284.Federal Law requires that we warn you of the following: 1. Natural methods can sometimes backfire. 2. If you are pregnant, consult your physician before using any natural remedy. 3. The Constitution guarantees you the right to be your own physician and toprescribe for your own health. We are not medical doctors although MDs are welcome to post here as long as they behave themselves. Any opinions put forth by the list members are exactly that, and any person following the advice of anyone posting here does so at their own risk. It is up to you to educate yourself. By accepting advice or products from list members, you are agreeing to be fully responsible for your own health, and hold the List Owner and members free of any liability. Dr. Ian ShillingtonDoctor of NaturopathyDr.IanShillington