Invisible Disease? - surgical revisions

I had posted on the idea of invisible diseases before. These are hospital related ailments that fewwant made public, and seldom discussed. Some of these may be iatrogenic, but often they are problems associated with management or policy issues. Hospital infection was one of these, and so was medication error. You can add the IVF mistakes to the list. Hospitals/clinics don't really track these problems, and even if they do you don't get to hear of them because no one wants to look bad. So the consumer is none the wiser.

One problem that was brought to my attention was that of surgical revisions, as a consequence of implants and prostheses etc. Unbeknownst to the public, this can be particularly problematic. You see, unlike drugs, which undergo extensive preclinical and clinical testing, medical devices are onlty minimally tested. There are few procedures to regulate the entry of these untested prosthesies and implants into the market, and we have no idea how many of the numerous implant/prosthesis fail, or how many patients need to undergo surgical revisions for these implants.

These figures are obviously important for the patient, but no one tracks these numbers and the surgeons are obviously not going to tell the patient how bad their figures are.

Maybe it's time for HSA to relook this blindspot in the regulation of medical devices so that patients can be better protected. At least they should be aware of the quality of the implants and prostheses being put into their bodies.

Here is some data I manage to pull out from a Swedish study on hip implants.

Makela et al. J Bone Joint Surg Br. 2008 Dec;90(12):1562-9.

IVF blunders - Time for a syscheck, Singapore?

Today's Straits Times, prompted by a recent IVF blunder in an UK fertility clinic, carried a report of the rather sloppy processes at such clinics. A recent Daily Mail report can accessed here.

I must say I haven't really thought much about this issue before, but was rather horrified at how frequent mistakes were. The ST report cited a Telegraph report alluding to as much as a staggering 40 mistakes per 10,000 cycles in 2006-07 (up from 15/10,000 in 2003-04). The Daily Mail refers to a report due soon showing 200 such 'serious mistakes' and 'near misses' this year. (The British Fertility Society however without citing figures, reassures that these errors are 'extremely rare'.

I am horrified.

An MOH report 2004/5 on IVF can be found here. In 2002 there were 1569 IVF treatments. Todate we must have done way beyond 10,000 treatments, but I can't find any data on IVF errors in Singapore. Are we that error free? Or have the errors been swept under the carpet somehow?

MOH should enlighten us on how IVF errors are being monitored, or is it that no one wants to know or tell?

Medication errors - no one wants to find out...

News report today of a medication error that came to light only because the patient's family made it public. Honest mistake by a sincere, decent doctor. But potentially tragic.

Medication errors occur much more commonly than the public is aware of. (I personally heard of recent incident in a local major hospital.) A recent report (2006) by the National Academies of Science highlighted this problem and estimated that medication errors harm at least 1.5 million people every year in the US. The medical costs in managing these errors amount to some US$3.5 billion. Awareness and simple solutions can prevent many of these problems.

Unfortunately no one locally seems to be interested. The hospitals don't want to know. And obviously do not have any means to track this problem. The Ministry of Health show no interest in auditing this problem and is quite content to let the hospitals manage the problem by sweeping everything under the carpet.

See no evil, hear no evil - and no evil shall be spoken, seems to be the motto.

Invisible Disease - Medication errors

Just as we had been discussing the invisible diseases in hospitals, here is a recent report (hot off the press!) of an Austrian study on medication errors across 113 intensive care units in 27 countries. Participants were 1328 adult patients in ICUs. This was an observational, prospective, 24 hour cross sectional study with self reporting by staff.

The results?

"861 errors affecting 441 patients were reported: 74.5 (95% confidence interval 69.5 to 79.4) events per 100 patient days. Three quarters of the errors were classified as errors of omission. Twelve patients (0.9% of the study population) experienced permanent harm or died because of medication errors at the administration stage." (Cited from the original paper BMJ 2000 320: 745-749)

Their conclusions?

"Parenteral medication errors at the administration stage are common and a serious safety problem in intensive care units. With the increasing complexity of care in critically ill patients, organizational factors such as error reporting systems and routine checks can reduce the risk for such errors."

We will not likely ever, to find out what the situation is in Singapore. It's an invisible disease. No one wants to know. Neither the hospitals nor the MOH wants to find out.

But the public has a right to know.

Invisible diseases...

Used that term, and need to explain abit more...

Invisible diseases??

They are just stuff that occurs in clinical practice that adversely affects the patients without their realizing it, and that doctors and hospitals like to pretend don't exist. They are just invisible. Until someone points them out.

What are some of these?

For one thing, diseases caused by doctors. These are called in our jargon, iatrogenic diseases. Often just unsavoury outcome of a reasonable practice. But sometimes can be bad outcome of unsavoury practice. Side effects of drugs, for example.

Medication errors.

Bad surgery. How many of these surface? Do hospitals track poor/bad outcome?

Stuff like that. They remain largely invisible, because people wear blinkers and pretend they don't exist. Why? simply because they cost money to prevent, even though they will eventually save health care costs because preventing them decreases overall morbidity. And reduced morbidity will eventually save health care $$. But hospitals and doctors tend not to want to deal with this because their accounting is too simplistic to take into consideration health $$ savings of this nature. As long as the patient/consumer is prepared to pay for the increased morbidity, why bother spending money from your own coffers for good preventive medicine. You can't bill the patient/consumer for preventive measures.

Hospital (nosocomial) infections - an 'invisible' disease

Salma Khalik, Health Correspondent for the Straits Times had a good write up today (pg 2 ST) on stamping out hospital infections. Her comments resonated with what I had posted earlier, and points the finger at bottom line issues affecting the hospitals. She suggested an interesting solution. Make the hospitals liable for hospital (nosocomial) infections. She's right, of course. They should be. Why should patients have to pay extra if hospitals are responsible for infections inflicted upon the patients. It's like asking patients to pay for the extra surgery required if surgeons botch up their routine surgery (oooops...that happens too doesn't it?). Problem is hospitals will just pass on the costs of litigation, and of insurance back to the patients. And then up go health care costs.

This really underlies the difficulty in implementing solutions which we all know are required. Hospitals don't want to track nosocomial infections and don't really want to know about it no matter what they profess. And MOH also doesn't really want to track the problem, nor seriously deal with it. Ministry of Health needs to keep health care costs down, or else pay the political price.

It's all lip service at the moment, because the numbers are still manageable. Many patients are not even aware they have picked up nosocomial infections, or that their hospital costs are high because they needed that expensive special antibiotic, or that extra long stay to deal with an unnecessary superinfection by a resistant bug. It is really one of several 'invisible diseases'....ailments that doctors pretend not to see, and for which patients willy nilly accept as part of their hospital experience. And pay for it. What choice do they have?

So as long as patients happily pay the cost of their superinfections, its really "hush everyone...don't tell anyone the problem exists".

Ultimately it is a problem that Ministry and hospitals have to take responsibility for. No doubt health care costs will go up because of it, but someone has to pay for it...and someone other than the patient who was really an innocent victim of dirty facilities.