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Why Doesn’t Healthcare Improve Health?

Thanks gwern, I guess I just didn't see the big blue button with "Download Free PDF" (extrapolating — my patients will be dying at about a 1 in 3 rate).

Here are the important paragraphs (pgs. 27-29):

The most extensive study of adverse events is the Harvard Medical Practice Study, a study of more than 30,000 randomly selected discharges from 51 randomly selected hospitals in New York State in 1984.30 Adverse events, manifest by prolonged hospitalization or disability at the time of discharge or both, occurred in 3.7 percent of the hospitalizations. The proportion of adverse events attributable to errors (i.e., preventable adverse events) was 58 percent and the proportion of adverse events due to negligence was 27.6 percent. Although most of these adverse events gave rise to disability lasting less than six months, 13.6 percent resulted in death and 2.6 percent caused permanently disabling injuries. Drug complications were the most common type of adverse event (19 percent), followed by wound infections (14 percent) and technical complications (13 percent).[1] [2] [3]

The findings of the Harvard Medical Practice Study in New York have recently been corroborated by a study of adverse events in Colorado and Utah occurring in 1992.[4] This study included the review of medical records pertaining to a random sample of 15,000 discharges from a representative sample of hospitals in the two states. Adverse events occurred in 2.9 percent of hospitalizations in each state. Over four out of five of these adverse events occurred in the hospital, the remaining occurred prior to admission in physicians’ offices, patients’ homes or other non-hospital settings. The proportion of adverse events due to negligence was 29.2 percent, and the proportion of adverse events that were preventable was 53 percent. As was the case in the New York study, over 50 percent of adverse events were minor, temporary injuries. But the study in New York found that 13.6 percent of adverse events led to death, as compared with 6.6 percent in Colorado and Utah. In New York, about one in four negligent adverse events led to death, while in Colorado and Utah, death resulted in about 1 out of every 11 negligent adverse events.

Extrapolation of the results of the Colorado and Utah study to the over 33.6 million admissions to hospitals in the United States in 1997,[5] implies that at least 44,000 Americans die in hospitals each year as a result of preventable medical errors. Based on the results of the New York study, the number of deaths due to medical error may be as high as 98,000. By way of comparison, the lower estimate is greater than the number of deaths attributable to the 8th-leading cause of death.

The important takeaways:

  • Negligence is responsible for something like 30% of these events.
  • "Preventable" errors (e.g. drug complications) are responsible for something like 50%.
  • Interestingly, negligence ("care that fell below the standard expected of physicians in their community"[6]) was more frequent among the more severe outcomes (around 50% of the deaths). [1]
  • It helps to be young. "Persons 65 or older had more than double the risk of persons 16 to 44 years of age" [1]

The main thing I'm wondering is how many of these "deaths due to negligence" are actually just examples of triage. I.e.: Doctors have intuition about who is/isn't going to make it, and they decide to forego interventions that would postpone the inevitable. I'm not a doctor, but I can imagine these kinds of intuitions are hard to convey in medical records. 

But even if we choose to ignore all adverse deaths caused by negligence (=50%), we still have between 20,000 (the Colorado/Utah study[3]) and 50,000 (the New York study[1][2]) iatrogenic deaths. That's in the range of suicide (#11) to road injuries (#8)[7]. Not good.

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    Still looking for this one (American Hospital Association. Hospital Statistics. Chicago. 1999) [Statista]( says 36.2 million hospital admissions in the US in 2019.

  6. ^

    Assessed by two independent physician-reviewers looking over randomly sampled medical records. 

  7. ^

    [35k to 47k in 1997]( 

Why Doesn’t Healthcare Improve Health?

Does anyone have a link to the original “To err is human” study? Seems to only be available in paperback.

Something about this study strikes me as not quite right. It doesn’t seem obvious to me that the adverse effects discussed translate to “killed by doctors” or even necessarily “medical mistake”:

  • Suppose a doctor had discovered one of these medical mistakes on time. That doesn’t necessarily mean that doctor could have done anything about it.
  • Suppose you’re a patient in a hospital and the base rate for fatality risks is something like one per day. Suppose also that in this hospital the doctors actually are 100% perfect at resolving each fatality risk. However, your doctors make a mistake in diagnosis 5% of the time. Well then, after a month in the hospital, your odds aren’t looking too great (80% chance you’re in a coffin).

Sure, in the second case, you could say that your hospital has a 5% “killed by doctors” rate, but you could also take the more generous view that this patient was sick as a dog, and ultimately it was the cruel hand of iterated probabilities that dealt the final blow.

When I think “killed by doctor”, I’m thinking of cases where doctors explicitly prescribed some substance or therapy that caused death. I’m less sure about death by neglect.

But I wholeheartedly agree that in general, healthcare is messed up. We’re overmedicating and overmedicalizing, it’s eating into our pockets, and it’s not making us much healthier.

Grandpa Has Different Rules

Her report. Also this was only a “problem” (not the actual eating disorder kind of problem) as a kid.

But like I said, it’s anecdotal, there’s no RCT taking place here, so discount everything appropriately.

Grandpa Has Different Rules

I have to respond to the fractional sweets thing.

My partner’s parents (her dad mostly) enforced an 8-point rule around candy. One m&m = 1 point; 1 starburst = 4…

The consequence? She developed an unhealthy relationship to candy and would binge on sugary garbage whenever with friends whose parents did not enforce the rule. She didn’t get a chance to discover her own limits for herself.

Contrast with my upbringing: there just wasn’t candy in house, and my parents were relatively relaxed outside the house (granted breakfast was still garbagey cereal but standards change). I never had a problem over consuming candy.

I guess the takeaway is that (human-)enforced moderation is much more fragile than passive (environmentally enforced) moderation.

But then, if I consider how different our siblings are from us (my brother has way more of a sweet tooth, and my partner’s sister had less of a sweet tooth than her), I’d have to conclude that none of this matters, kids are their own creatures, and everything I just wrote only counts as the weakest possible kind of evidence. Oh well.

(briefly) RaDVaC and SMTM, two things we should be doing

In the same vein—Isn’t about time for the rationalist community to found a little city? A place maybe somewhere in Canada, nice and isolated from climate impacts, altitudinally disposed against obesity, enough LED wattage to offset the extra microSADs…

But in all honesty, we’d get to test better voting systems, bring smart minds together, pioneer new education plans, and obviously explore how to achieve autarky.

You could start it off small— as a mini hub for organizing retreats. Offer EA grants to come work there. Slowly expand outwards.

If we carry on the rest of the planning phase on paper and pencil, who knows, maybe we can even keep it secret from the AI overlord.