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infections occurring per 100 admissions, which is a rate of 5-6%. However, because of progressively shorter in-patient stays and the increasing number of admissions, the actual number of infec- tions increased. It is estimated that in 1995, nosocomial infections cost $4.5 billion and contributed to more than 88,000 deaths in the USA— one death every six minutes.’ The 2003 incidence of nosocomial mortality is quite probably higher than in 1995 because of the tremendous increase in antibiotic-resistant organisms. Morbidity and Mortality Weekly Report found that nosocomial infections cost $5 billion annually in 1999." This is a $0.5 billion increase in four years. The present cost of nosocomial infections may now be in the order of $5.5 billion. The study surveyed 750 recently ill adults in five different countries. The breakdown by country showed 18% of those in Britain, 25% in Canada, 23% in Australia, 23% in New Zealand, and 28%, the highest percentage, in the United States.'" HEALTH INSURANCE FRAUD A recent finding by the Institute of Medicine is that the 41 mil- lion Americans without health insurance have consistently worse clinical outcomes than those who are insured, and are at increased risk for dying prematurely.'* When doctors bill for services they do not render, advise unnecessary tests or screen everyone for a rare condition, they are committing insurance fraud. The US General Accounting Office (GAO) gave a 1998 figure of $12 billion lost to fraudulent or unnecessary claims, and reclaimed $480 million in judgements in that year. In 2001, the Federal government won or negotiated more than $1.7 billion in judgements, settlements and administra- tive impositions in health-care fraud cases and proceedings.'* Out-patient latrogenesis or unnecessary claims, and reclaimed $480 million in judgements Dr Barbara Starfield in a 2000 JAMA paper presents us with in that year. In 2001, the Federal government won or negotiated well-documented facts that are both shocking and unassailable: more than $1.7 billion in judgements, settlements and administra- 1. The US ranks 12th out of 13 countries in a total of 16 health tive impositions in health-care fraud cases and proceedings.'* indicators. Japan, Sweden and Canada were first, second and third. WAREHOUSING OUR ELDERS 2. More than 40 million people It is only fitting that we end this have no health insurance. report with acknowledgement of our 3. 20% to 30% of patients receive elders. The moral and ethical fibre of contraindicated care. ; It is estimated that in 1995, society can be judged by the way it Dr Starfield warns that one cause of treats its weakest and most vulnerable medical mistakes is the overuse of nosocomial [hospital-related] members. Some cultures honour and technology, which may create a "cas- i i i respect the wisdom of their elders, cade effect" leading to more treatment. infections...contributed to keeping them at home—the better to She urges the use of ICD more than 88,000 deaths continue participation in their commu- (International Classification of i —_— nity. However, American nursing Diseases) codes which have designa- in the USA one death homes, where millions of the nation's tions called: "Drugs, Medicinal, and every six minutes. elders die, represent the pinnacle of Biological Substances Causing social isolation and medical abuse. Adverse Effects in Therapeutic Use" Here are some important statistics and "Complications of Surgical and about nursing homes: Medical Care" to help doctors quantify 1. In America at any one time, and recognise the magnitude of the medical error problem. approximately 1.6 million elderly people are confined to nurs- Starfield says that, at present, deaths actually due to medical ing homes. By 2050, that number could be 6.6 million.''"''° error are likely to be coded according to some other cause of 2. A total of 20% of all deaths from all causes occur in nursing death. She concludes that, against the backdrop of the abysmal homes.” US health report card compared to the rest of the Westernised 3. Hip fractures are the single greatest reason for nursing countries, we should recognise that the harmful effects of health home admissions.''* care interventions account for a substantial proportion of excess 4. Nursing homes represent a reservoir for drug-resistant deaths in the USA. organisms due to overuse of antibiotics.'"” Starfield cites Weingart's 2000 paper, "Epidemiology of Congressman Waxman reminded us that "as a society we will Medical Error", on out-patient iatrogenesis. And Weingart, in be judged by how we treat the elderly" when he presented a turn, cites Johnson and Bootman, who asked pharmacists to esti- report that he sponsored, "Abuse of Residents is a Major Problem mate the probability of adverse outcomes occurring as aresultof in US Nursing Homes" on July 30, 2001. The report uncovered out-patient drug treatment. Statistics showed that between 4% that one third—5,283 of the nations’ 17,000 nursing homes— and 18% of consecutive patients in out-patient settings suffer an were cited for an abuse violation in the two-year period studied, iatrogenic event leading to:'* January 1999-January 2001.''° Waxman stated that "the people 1. 116 million extra physician visits; who cared for us deserve better". He also made it very clear that 2. 77 million extra prescriptions; this was only the tip of the iceberg and there is much more abuse 3. 17 million emergency department visits; occurring that we don't know about or ignore." 4. 8 million hospitalisations; The major findings of the report were: 5. 3 million long-term admissions; * Over 30% of nursing homes in the US were cited for abuses, 6. 199,000 additional deaths; totalling more than 9,000 abuse violations; 7. $77 billion in extra costs. * 10% of nursing homes had violations that caused actual phys- ical harm to residents, or worse; IT'S A GLOBAL ISSUE * Over 40% or 3,800 abuse violations were only discovered A survey published in the Journal of Health Affairs pointed out after a formal complaint was filed, usually by concerned that between 18% and 28% of people who were recently ill had family members; suffered from a medical or drug error in the previous two years. * Many verbal abuse violations were found; It is estimated that in 1995, nosocomial [hospital-related] infections...contributed to IT'S A GLOBAL ISSUE A survey published in the Journal of Health Affairs pointed out that between 18% and 28% of people who were recently ill had suffered from a medical or drug error in the previous two years. NEXUS + 27 more than 88,000 deaths in the USA—one death every six minutes. DECEMBER 2004 — JANUARY 2005 www.nexusmagazine.com