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Journal of the Academy of Hospital Administration

Notes, News and Journal Scan

Author(s): Sidhartha Satpathy

Vol. 16, No. 2 (2004-07 - 2004-12)

Key Messages:

  • Mexico Summit on Health Research reaffirms funding for projects to reduce inequity and social injustice.
  • Germany sets up quality Control Institute for Healthcare lines of NICE in UK.
  • Health Grades, an US based firm grades hospitals in term of safety and claims that majority of incidents are preventable. Research reaffirm funding for projects to reduce inequity and social injustice.
  • A Factorial survey, on disclosure of medical errors.

1. The Mexico Summit on Health Research 2004

Kamran Abbasi States in a BMJ editorial that governments should fund the necessary health research to ensure vibrant health systems and to reduce inequity and social injustice, health ministers urged at the conclusion of the summit on health research held in Mexico last week.

Fifty eight ministries of health were represented half by ministers, at the four day summit, which was designed to build momentum for a global initiative to strengthen health systems through research and in the process to help achieve the United Nations' millennium development goals. A 10 point call for action was agreed by the ministerial representatives. The annual meeting of the Global Forum for Health Research, held in parallel, also issued a statement calling for research to be used to improve equity in global health.

Some delegates, however, expressed concern that the ministerial call for action was short on concrete steps. Dr. Tim Evans, Head of WHO's Evidence and Information for Policy Department and responsible for the initiative, acknowledged this concern and warned against complacency ahead of the next ministerial summit, planned for 2008.

The call for action will be further refined and presented to the next executive board meeting of WHO and then put forward for agreement at next year's World Health Assembly.

But what will the millions of poor people in our world make of the Mexico Agenda for Health Research, a document agreed by health representatives from 59 states? What will they make of the call for action that makes only three points that can be immediately translated into actions?

  1. The first of these is a commitment to producing national research agendas.
  2. The next is commitment to supervise a network that will coordinate the various clinical trial registries and make them talk to each other and the world in a transparent manner. Trial registration is a good start but how do we know that this good practice will spread to the majority of health systems research any time soon?;
  3. The final concrete action is an administrative plan to revisit this issue at future meetings that will review the millennium development goals and a second ministerial summit in 2008.

The world's poor, of course, will probably say none of this because they struggle to have their voice heard. They also failed to be represented in the group that drafted the agenda for the ministers to agree, haggle over, and sign off-a glaring omission, affecting the perceived authenticity of the agenda. Much of the talk at this meeting was of demand led solutions, pull not push. In that context an agenda drafted largely by representatives of the rich and not the poor, was a folly. A second folly is to tie everything under the sun to achieving the millennium development goals.

Tim Evans, the assistant director general at WHO responsible for turning these fine words into firm actions, made it clear that all those gathered at Mexico are accountable to the world's poor. Performance measures must be in place to judge the success of this year's summit when the next one comes around in 2008, he said. Fine words – and now for action.

BMJ Vol. 329 ; 27 Nov 2004 ; p1249-50, 1258.

2. Germany Sets up Quality Control Institute for Health Care

Annette Tuffs from Heidelberg reports in BMJ that Germany's federal joint committee of doctors, health insurance companies, and patients (the Gemeinsame Bundesausschuss) has announced the foundation of a new, independent Institute for Quality and Economic Efficiency in Health Care-Germany's equivalent of England's National Institute for Clinical Excellence. The main task of the new institute, which has a staff of about 30, is to research the latest medical knowledge on diagnostics and therapy of selected diseases and provide expertise on quality and economic efficiency.

The institute will also evaluate the evidence based guidelines of the most common diseases and prepare recommendations for setting up disease management programmes. In addition, the institute will evaluate the effectiveness of drug treatment and prepare information about the quality and efficiency of health care for the public.

Its first director is Professor Peter Sawicki, a physician and diabetes specialist who founded a private research institute, the Institute for Evidence-Based Medicine, in 2002 (BMJ 2004 ; 328 : 485).

The establishment of the Institute for Quality and Economic Efficiency in Health Care has already been criticised by doctors and the pharmaceutical industry. Doctors fear that they will be confronted with "cookery book medicine" and "patronising state medicine", which will abolish every chance of giving individual treatment. They welcome, however, more scientifically based advice on effective drug treatment. The drug industry is sceptical of yet another bureaucratic obstacle to the introduction of innovative drug treatment.

BMJ, Vol. 329 ; 7 Aug 2004, 307.

3. How Not to Grade Hospital Safety

A Lancet editorial states that the number of jumbo jets crashing a day is not a common statistic in mortality measurement, and seems designed to catch attention. But such a denominator features highly in Patient safety in American hospitals, a recent report by Health Grades, a US company that rates health care. According to their press release: "The equivalent of 390 jumbo jets full of people are dying each year due to likely preventable, in-hospital medical errors." Health Grades studied 37 million hospital admissions by Medicare patients in 2000-02, and found 1.14 million patient- safety incidents. Nearly 324,000 patients who had such an incident died, and Health-Grades says that nearly 264,000 (81%) of these deaths were potentially attributable to the incident. Not only that, says the report, but the safety events cost hospitals an extra US$2.85 billion a year.

If a fifth of this excess attributable mortality could be prevented in four key areas, the Health Grades' report continues, 18000 Medicare patients a year could avoid dying due to a hospital error. The key areas are failure to rescue (ie, to diagnose or treat in time), decubitus ulcer, postoperative sepsis, and postoperative pulmonary embolism or deep-vein thrombosis.

Health Grades used a set of safety indicators developed by the federal Agency for Healthcare Research and Quality that were not designed to model excess mortality or costs. Health Grades bravely extrapolated attributable mortality and costs from a 2003 paper in JAMA, which studied all payers at all ages and excluded failure to rescue, into the Medicare elderly population. But Medicare patients are obviously sicker, more likely to have concurrent diseases, and their adverse-event rates will be higher. Finally, Health Grades should not have assumed that deaths after failure to rescue are necessarily preventable.

Overall, the Health Grades' data are probably an over-estimate. On the same day, Health Grades used the same criteria to list the top 7.5% of hospitals with the best safety record-probably not the way to choose one's place of treatment., Vol. 364, 7Aug 2004, p476

4. What Makes an Error Unacceptable?
A Factorial Survey on the Disclosure of Medical Errors

David L.B.Schwappach and Christian M.Koeck in an article in the International Journal for Quality in Health Care mention that although the importance of disclosing medical errors to patients has been argued, little is known about the relative effect of different attributes of error handling and communication on patients' judgements about errors.

Objectives: This study investigates how different characteristics of medical errors and of physicians' subsequent handling of errors contribute to patients' evaluations of the incident and their attitudes towards potential consequences and sanctions for the physician.

Materials and Methods : A factorial survey using the vignette technique presented hypothetical scenarios involving medical errors to members of the general public in an Internet- based study. Members of a German Internet survey panel participated (n=1017). Multiple ordered logistic regression models were estimated to explain citizens' judgements of error severity and their attitudes towards reporting of errors, wishing for referral to another physician, and supporting sanctions against the health professional involved as a response to characteristics of the presented errors.

Results: While the severity of the outcomes of errors remains the most important single factor in the choice of actions to be taken, the professional's approach to the error is regarded as essential in the overall evaluation of errors and the consideration of consequences. In errors with a severe outcome, an honest, empathic, and accountable approach to the error decreases the probability of participants' support for strong sanctions against the physician involved by 59%. Judgements were only marginally affected by respondents' characteristics.

Conclusions: The handling of errors strongly contributes to citizens' choice of action to be taken, and they are sensitive to failures to name the incident as an ‘error'. For the success of de-individualized, systems-oriented approaches to errors, communication of clear accountability to patients will be crucial.

Note: The full article can be accessed in International Journal for Quality in Health Care 2004, Vol. 16, No.4, 317-326.

* Assoc. Prof. Deptt. of Hospital Administration, AIIMS, New Delhi
Journal of the Academy of Hospital Administration, Volume 16 No. 2 July-December 2004

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