Iatrogenesis in the NY Times

Here's a NY Times article about No-Fault style systems for iatrogenesis.

- posted by Ethan at 5:09 PM; link

 
Playoff Time

So it's Sox / A's and Twins / Yankees. Before the introduction of the wild card, it would have been Yankees vs. A's in the pennant, with the best offense in decades (at least!) sitting at home, and licking its old wounds. Certainly there are flaws with the wild card. For one thing, it makes it less likely that the World Series winner will actually be the best team (though the whole idea of a playoff system, when there's inter-divisional play and even inter-league play, doesn't help identify the best team). Still, without it, the Yankees wouldn't have qualified for the playoffs in either 1996 or 2000, so it's got some place in my heart. And it certainly does keep more teams involved.

On another note, here's something that bothers me. Certain hosts on the local sports radio station (WEEI) have criticized Billy Beane's A's for never having won a playoff series, sometimes mentioned in the same breath as Kevin Garnett's Timberwolves. (yes, I realize the funny juxtaposition) Winning a baseball playoff series is not the same thing as winning as playoff series (or game) in any of the other major team sports. First of all, there are half as many playoff teams in baseball as there are in basketball or hockey; that means a first-round series in baseball is like a second-round series in either of those sports, in terms of strength of competition. And by its nature, it's a lot harder to dominate in baseball: there's more luck involved than in any of the other sports, and in general, the skill level is more even.

(One bit of evidence for that: the best winning percentage of a baseball team last century was the 1906 Cubs, at .7532 (116 - 38). An NBA team that finishes with 62 wins has a winning percentage of .756; that doesn't happen every year, but it's not very are. Michael Jordan's 1997 Chicago Bulls (72 - 10) finished at .8780.)

Anyway, the point is that luck has a greater role in baseball. Combined with the increased quality of competition in baseball's playoff seriers, it doesn't make sense to evaluate the A's as though they were a basketball team.

- posted by Erik at 10:55 AM; link

 
Iatrogenesis - Indirect Costs

In my last piece I wrote about the direct costs of iatrogenesis. Today I'm going to write about the indirect costs.

Over the last few years the problem of rising medical malpractice insurance premiums for physicians has been in the public eye. It is widely reported (and somewhat exaggerated) in the media that doctors in certain sub-fields of medicine in some states have closed down their practices because they became unprofitable as a result of the rising malpractice insurance premiums. This summer, the General Accounting Office released a report on the causes of rising premiums, and the results are what you would expect.

It is true that these rates have gone up "dramatically" since the late ‘90s, though the increase varied between different sub-fields and by geographic location. For example, the GAO estimates that the increase for general surgery varied between 2% and 130%.

The causes for such increases are several:

During the early ‘90s there was greater competition in the medical malpractice insurance market. That is, there were more providers competing for the business of doctors and hospitals. Many insurers were forced to offer insurance at low prices, sometimes even at a price below their cost, in order to attract business. Today there are fewer providers, and the competition is therefore less.

During that same period in the early ‘90s the investments of insurance companies were more profitable. This allowed them to offer lower premiums because they had investment income to cover their loss. Today the investments of insurance companies are not doing well because of the economic recession forcing them to cover their costs with higher premiums.

Some of the same issues affecting medical malpractice insurers are causing the costs of reinsurance to rise. Reinsurance is insurance for insurers. That is, insurers get insurance that protects themselves against catastrophic financial losses, and these reinsurers are raising their premiums because of lower investment profits as a result of the economic recession.

But, according to the GAO, the largest cause of the rise in medical malpractice insurance premiums is the greater costs of malpractice claims. There are really three issues in one. First, the average compensation won in a medical malpractice tort suit has gone up. Second, the number of medical malpractice tort suits has gone up. Third, the percentage of medical malpractice tort suits that are won by the plaintiff has gone up.

A related issue is whether doctors are practicing "defensive medicine," that is, doing things like ordering lots of extra tests they don't think the patient needs out of fear that they will miss something and be sued. Such defensive medicine practices are believed to be widely prevalent and costly, but the GAO report cites problems with the studies on this issue and says that precise estimates of the costs of defensive medicine are not available.

My next piece will be a critique of medical malpractice tort reforms and some other methods of controlling the costs of medical malpractice insurance, including proposals for specialized health courts. The following piece will be about a two-pronged proposal that I think will be more effective in addressing the problem of iatrogenesis and its related costs.

- posted by Ethan at 12:24 PM; link

 
Courting Pennsylvania

Here's an interesting article, from the Post, on the Bush administration's attempt to pick up votes in West Virginia and Pennsylvania using steel tariffs. At the very least, it's a good reminder, to those of us who sometimes forget, that labor unions still play a significant role in American politics. As recently as 1985, labor unions were viewed as one of the two most politically influential groups in American society (along with the media).

By the way, Bush's approval rating has dropped below 50% for the first time in his tenure.

- posted by Erik at 12:10 AM; link

 
Re: Oui Shall Overcome

Bob,

Surely you don't mean to insinuate that an Austrian emigre body-builder cannot have a long-standing interest in promoting an economist widely associated with the Austrian school of economic thought? There is evidence to the contrary.

- posted by Mark at 12:20 PM; link

 
Why I will never eat another potato chip for charity

Here's a story about another heartless "crisp"-related prank in Britain.

- posted by Mark at 5:24 PM; link

 
Zagat's Guide to Music

Zagat has published a new guide to music, after the model of their restaurant guides. The yahoo article provides a few interesting lists (top break-up albums, make out albums, favorites by genre, etc.). Here's one that catches my eye:

Most Influential Musical Artists:

1. The Beatles
2. Elvis Presley
3. Bob Dylan
4. The Rolling Stones
5. Madonna
6. Led Zeppelin
7. U2
8. Bruce Springsteen and the E Street Band
9. Frank Sinatra
10. Michael Jackson

Not a single African-American on the list, unless you count Michael Jackson. I'm sure there are problems with figuring out who's influential, and yes, it seems we're just looking at what's influenced contemporary pop music. But surely, there's a blues guitarist out there somewhere who's influenced more people than Jimmy Page.

- posted by Erik at 1:23 PM; link

 
Iatrogenesis

Iatrogenesis is injury caused by doctors and health care institutions. It can be through intentional acts, recklessness, negligence, or accidental acts. It can be the result of a single human act, a poor mangement system, a fuse burning out, etc. All iatrogenic injury is worth investigating and trying to understand how it might be avoided, but I will mostly be dealing with injuries caused by negligence.

I'm going to solve the Medical Malpractice Tort Problem. Not today, but soon. For today, let me give some numbers to show that the problem of medical negligence is not simply a matter of interest to eager plaintiff's attorneys.

There have been two large, reputable studies on the rate of medical error and the subsection of that error that is due to negligence (medical malpractice). One is The Report of the Harvard Medical Practice Study to the State of New York (1990). The second is the Utah-Colorado Medical Practice Study ("UCMPS"). In both studies, the tens of thousands of hospital medical records for a year were screened by nurses for iatrogenic injury. Then those hospital medical records with medical error were screened by physicians for negligence (note the distinct absence of lawyers from this process). Both studies found that three to four percent of hospitalizations give rise to iatrogenic injury, and that about 28% of these were the result of negligence (about 1% of total hospital discharges). It should be pointed out here that these numbers do not include medical error that did not cause injury (luck, close-calls, resilience of the patient, etc.). Another study calculated that over 36% of patients admitted to hospitals develop iatrogentic illnesses. (304 N.Eng.J.Med. 638, 641 (1981). Think about this the next time you or a loved one is hospitalized.

Trying to calculate the direct costs of iatrogenic illness (just the medical costs, not legal costs, insurance costs, or "defensive medicine" costs) is very difficult, but a couple of studies have put the number at approximately 1.3% of a hospitals total patient-service billings. (304 N.Eng.J.Med. 634, 635 (1981); 302 N.Eng.J.Med. 996 (1980).

The Report of the Harvard Medical Practice Study estimated that the rate of law suit for malpractice was about 1/8th the actual rate of medical malpractice, and that the number of people who were compensated by the tort system was about 1/16th the actual rate of medical malpractice. They point out that there appeared to be little correspondence between those who actually suffered negligence and those who filed law suits, and that there was little correspondence between those who won compensation through the tort system, and those who suffered negligence.

There are probably a number of reasons for this. First, people who suffer small injuries are unlikely to sue because it is a lot of trouble and because lawyers won't take the case on a contingency fee basis without a chance of winning enough money to make it profitable. Second, the hospital may fix the injury and/or compensate the injured patient directly. Third, the hospital's medical malpractice insurer may decide to offer a settlement that is accepted by the patient before the patient files a law suit. Forth, many people do not sue because they do not believe they can, do not realize that their injury is due to negligence, or do not want to because they are embarrassed for one reason or another.

Nevertheless, it appears that the tort system may do a bad job of compensating those injured by medical malpractice both because of its lack of use or unavailability, and because of the inaccuracy in its results. This also means that the tort system fails to encourage doctors to be careful because whether or not they are taken to court or whether or not they win in court does not depend upon whether they were negligent.

My next piece will be about the indirect costs of iatrogenesis, including the issue of rising premium rates for medical malpractice insurance. The piece after that will address some proposals for a special medical malpractice court to increase the accuracy of court judgements. The piece after that will be my proposal for a new kind of medical licensing and accrediation system for reducing negligence.

- posted by Ethan at 11:17 AM; link

 
On "not being gutsy enough"

Steve Johnson at the Chicago Tribune dealing with the issues others are too tactful to address:

"The outcry of conventional wisdom, that the series [8 Simple Rules For Dating My Teenage Daughter] should have been canceled out of respect for Ritter, does the actor a disservice.

Respect the fine work he did while alive, but don't demand some grandiose gesture of fake sentimentality too. It wouldn't bring back Ritter, and it would likely lead to one more mediocrity in place of a show that was at least tolerable."

This article really has to be read in its entirety to be believed.

- posted by Mark at 11:21 PM; link

 
The Polish Case for "Scolding" France

The question discussed before was whether the US should "scold" France, i.e., whether, as observers, we should approve of their decision not to support the war in Iraq. Now that France and Germany seem likely to support joining the effort to rebuild Iraq - but at a cost - there is a more practical question: how to deal with them now.

This article, by AEI fellow and former Polish deputy minister of foreign affairs, Radek Sikorski, gives a convincing and interesting account of the Polish approach to foreign policy during the war. Poland, which, according to Sikorski's account, is a small player in the EU, gave military support to the war in Iraq, in the hopes of solidifying its alliance with the US.

Poland, one of a few countries which supported the war, did not receieve financial support from the US beyond Pentagon allocations for transporting troops, now wonders just what they got by supporting our war. In Sikorski's words:

"U.S. leaders, on the other hand, undoubtedly know that we in the countries of the anti-Saddam coalition remember whether it is worth being a friend to the United States in time of need, or whether it is more advantageous to kick it while it is down and to wait until it agrees to our demands. "

There are a few interesting things about this comment. First, he does not mention any direct interest Poland had in the war; the only goal he mentions is improving US-Polish relations. More importantly, he suggests a case for denying those who did not support the war benefits in post-war Iraq: it does not make sense for the US to set a precedent of forgive-and-forget.

Now, our relations with France are clearly more important than our relations with Poland. France is more influential in Europe, and is a permanent member of the Security Council. However, the US ought to realize that if it buys French support at this point, it will risk the strength of alliances with nations who did side with it during the war.

- posted by Erik at 10:50 PM; link

 
Osama B. Laden

C. Hitchens makes an interesting case here that Osama Bin Laden is dead. Perhaps it's wishful thinking, but he does make you suspicious.

- posted by Mark at 10:40 PM; link

 
Fear of Alien Bacteria Pt. I & II

"The Galileo spacecraft ended its 14-year mission of planetary exploration last night in a fiery suicide dive into Jupiter's crushing atmosphere.
Nasa scientists sent Galileo to its doom to prevent the unmanned probe contaminating one of Jupiter's moons with "stowaway" bacteria from Earth."
--David Derbyshire at The Telegraph Online


"Still, the discovery of just a single bacterium somewhere beyond Earth would force us to revise our understanding of who we are and where we fit into the cosmic scheme of things, throwing us into a deep spiritual identity crisis that would be every bit as dramatic as the one Copernicus brought about in the early 1500s, when he asserted that Earth was not at the center of the universe."
--Paul Davies in The Atlantic Online

[add.: In case it doesn't come across, I think the Davies quote is one of the stupidest things I've ever heard.]

- posted by Mark at 6:24 PM; link