Dying in Hospital - Adverse Drug Events in UK Hospitals - Controlling costs to control disease

Colin Norris, 32, a nasty arrogant staff nurse murdered four elderly patients with lethal injections of insulin at Leeds General Infirmary and St James's Hospital in Leeds ("Jimmy's" of TV fame) hospitals and has been given a 20 year sentence.

Dying in hospital is not an unusual event. It is a fate we all fear.

Dying or illness induced by the maladministration of medicines in a UK is not at all unusual. You don't need to meet a Colin Norris or a Beverley Allitt to die from an adverse drug event - events which have to be recorded by statute.

1 in 10 patents entering NHS hospitals will experience an “adverse event”, and 1 in a 100 will die as a consequence wrote the Editor of the British Medical Journal 0n the 8th April 2004.

Nothing has changed since then. Which is the reason that people like Norris - and don't think he is unique - can thrive in the NHS culture.

The unwillingness of the medical establishment, consultants, doctors, nursing staff, pharma companies and the NHS managing bodies, trusts and their elected and un-elected representatives to examine this dark secret within the health services is understandable, if regrettable.

Complacency and inertia well dosed with a wish to leave the washing of the medical profession's laundry in private is a powerful force.

It is even more regrettable that it is only after 60 years of the National and “free at the point of delivery” Health Service (NHS), which was apparently, until recently, “the envy of the world” are the “adverse” effects of hospital treatment being identified and studied.

Especially since Ivan Illych in the early 1970's in his book Medical Nemesis alerted the world to the problems of iatrogenic illness, that is, illness caused by medical treatment. In the UK efforts to quantify and cost these effects in monetary and wasted use of staff, time and resources. Only now are we shuffling towards framing sensible, rational plans to deal with these skeletons in the medical cupboard. Unlike say, the Netherlands where constant monitoring, high levels of isolation of affected patients and rigorous controls have almost completely removed the problem from hospital wards of Hospital Acquired Infections (HAI). A lesson we persist in refusing to learn.

Medical mistakes, misdemeanours, misunderstandings and resulting confusions and cockups are an apparently irredeemable consequence of organisations such as the NHS, the biggest employer in Europe. Plenty of studies on both sides of the Atlantic have shown the varying extent of dishonesty, incompetence and plain stupidity, the costs of which, both in health and money are exacerbated by the introduction of the legal process.

This has led to excessive litigation, overpaid greedy lawyers, fed and funded by obtuse thick skinned and bone headed bureaucrats unwilling to accept the realities of the world, anxious to both conceal and cover-up their organisation's mistakes and errors. Their medical colleagues meanwhile have continued to peddle the popular myths of modern medical practice with it's much publicized store of hi-tech wizardry, golden bullets and glamorous “brilliant” surgeons, fresh from their glitzy tours of the TV studios.

Staphylococcus infections, have been present for decades in UK hospitals, they frequently accelerated death for patients with terminal conditions, and consequently obtained the medically neutral and apparently benevolent description as “the old man's friend”. The problem was trivialised and ignored, a factor affected by changes in hospital management more anxious to control costs than disease. Resistant Staphylococcal aureus strains emerged (MRSA).

Strains appeared in hospitals world wide, often resulting from the use of massive doses of antibiotics, to control wound infections, increasingly because of the use of novel and extensive invasive surgical procedures, especially organ transplants, bio-mechanical implants and more recently the widespread use of very much improved dialysis methods as well as unnecessary catheterization of incontinent patients to relieve nursing care, reduce bed changes and control costs. There is broad agreement that 50,000 patients are affected each year in the UK with 5,000 deaths in hospital (at least) from HAI (not including deaths after discharge which are unknown but must occur).

To MRSA and the more recent epidemic of Clostridium difficile must now be added Multiple Drug Resistant TB (MDRTB) of which there have been (to date) a few isolated outbreaks and deaths which will increase due to in an increase hospitalised HIV / TB patients, especially of infected immigrants from Africa and increasingly Eastern Europe and the new EU states such as Estonia and Slovakia. There is reason to believe that MDRTB is where MRSA was 20/30 years ago – therefore effective prompt action is essential. Care costs for a single patient of MDRTB can be in the hundreds of thousands of pounds and an outbreak in millions.

A DRUGS DOWNER IN LIVERPOOL

Dr Munir Pirmohamed and colleagues in Liverpool reported in 2004 the consequences of admitting patients suffering from adverse drug reactions (ADR) in 2 Liverpool hospitals (BMJ Vol 329 3.7.04. p. 15-19). They studied 18,820 patients admitted over a 6 month period in 2001 over 16 years old, excluding all patients with deliberate or intentional overdosing and women with obstetric or gynaecological problems, a total of 1225 admissions.

This was the largest such study undertaken in the UK and showed that ;

Up to 6.5% of all admissions were related to ADRs, with a median age of 76 yrs compared with 66 yrs for all admissions and with a slight bias to females.

The median bed stay was 8 days or 4% of theoretical bed capacity (equivalent nationally, to seven 800 bed hospitals) involving, at average bed costs of £228 per day an annualised cost to the NHS of £466 Million.

1. 72% of the ADRs were by their definitions “avoidable”.
2. 2.3% of ADR patients died as a direct result of the ADR = 0.15% of all admissions, (broadly equivalent to reports of US experience.)
3. An annualised UK assessment indicates 5700 deaths of the 3.8 million acute hospital admissions per year. If ADRs subsequent to admission are added, this could indicate a total greater than 10,000 deaths per year. The authors indicate that deaths resulting from ADRs not admitted to hospital in primary care are probably equivalent in number. A possible total of 30,000 deaths per year in the UK.

The drugs responsible are in common and widespread use and are mainly basic drugs that have been in use a long time in general practice for many common conditions and include analgesics like aspirin and Non Steroidal Anti Inflammatory Drugs (NSAIDs) like diclofenac, diuretics, steroids such as prednisolene and blood thinning warfarin. Adverse effects may result from single use or in combination.

Besides the unsurprising call for more research, the authors conclude that it is incumbent on primary care prescribers to use the lowest dose necessary to achieve results, they identify evidence from others, that deaths related to aspirin (the cause of most problems and deaths of ADRs in the study, directly and in association with other drugs) could be reduced by 30% with a standard low dose of 75mg.

Funded by the Medicines and Healthcare Products Regulatory Agency (MHRA formerly Medicines Control Agency) the study highlights the needs for urgent action to reduce the burden on the NHS (presumably in money, wasted resource, and opportunity cost, and customer satisfaction), not to mention the anguish to patients and their families of illness, hospitalization and death. It is very good news that several of the authors sit on bodies and authorities who can pursue more research and effectively ensure that the necessary and urgent action is taken. Let us not forget that the initial report quantifying the costs of HAI from the NAO was published over 9 years ago.

What would be nice to report is that the pharmaceutical industry, to which antibiotics represent 2% of worldwide sales has produced a new antibiotic. It is 25 years since any antibiotic has been produced and there is not, nor is there any imminent possibility that a new and unexplored chink has been found in the biochemical pathways and metabolic systems of the major pathogens. These communicable diseases, TB, cholera, typhoid, malaria are now only ravaging the third world, which are set to increase with population growth and with increasing low cost international travel, legal and illegal immigration and the exodus of refugees from wars for resources.

Meanwhile the pharmaceutical giants are desperately seeking a new disease, called female sexual dysfunction, so they can double the market overnight for the lifestyle drug , sildenafyl citrate (Viagra / Cialis etc.,). The results so far, are disappointing. The lady really does have a headache. Lets hope she doesn't OD on the aspirin and end up as one more of the NHS ADRs and ends up boosting Dr Pirmohamed's revealing and alarming statistics.

See an earlier US study Reducing and Preventing Adverse Drug Events To Decrease Hospital Costs. Research in Action, Issue 1. AHRQ Publication Number 01-0020, March 2001. Agency for Healthcare Research and Quality, Rockville, MD.

"Over 770,000 people are injured or die each year in hospitals from adverse drug events (ADEs),1-3 which may cost up to $5.6 million each year per hospital4,5 depending on hospital size. This estimate does not include ADEs causing admissions, malpractice and litigation costs, or the costs of injuries to patients. National hospital expenses to treat patients who suffer ADEs during hospitalization are estimated at between $1.56 and $5.6 billion annually.4-7."

Note also ESF-UB Conference in Biomedicine Pharmacogenetics and Pharmacogenomics:
Adverse Drug Reactions - Hotel Eden Roc, Sant Feliu de Guixols ,Spain - 27 June – 2 July 2008
Chair: Munir Pirmohamed, University of Liverpool, UK
See Program here "Adverse drug reactions are a major problem for healthcare services, the pharmaceutical industry and regulators. This has been highlighted recently with some high-profile drug withdrawals and regulatory decisions." One thinks of Vioxx....