Last year around this time, I was profoundly shaken and continue to be deeply concerned by a paper from Academic Medicine by Lorna Lynn and her collaborators showing the low quality of chronic and geriatric care delivered in internal and family medicine residencies.

This year I was equally shaken by the report in the New England Journal of Medicine, “Temporal Trends in Rates of Patient Harm Resulting from Medical Care,” by Christopher P. Landrigan, M.D., M.P.H., and colleagues from Harvard, Stanford, IHI, and RAND. Their analysis of records of 2,341 cases at 10 hospitals sampled from North Carolina showed that there was no detectable improvement in rates of adverse events from 2002 to 2007, despite broad participation in quality and safety initiatives in the state, including IHI's Campaign for 100,000 Lives. I think that this paper needs careful consideration as it calls into question our naive assumptions about what will be required to improve the quality of health care.

The paper got good coverage both in the trade press and in the public media. But one of the best reflections I've read comes from Michael Millenson on the Health Affairs Blog. I wrote a rather impassioned response to his piece--which I am still waiting with some trepidation to see posted. I hope that I made sense and stayed reasonably rational, but I'm not sure.

On the Health Affairs Blog I wrote (I hope) that its author is right. "Adverse events," aka injuring people while trying to help them, are tolerated because the harms are largely invisible and conceived of as inevitable. We are all unwilling to face the degree of change in the health care system that would be required to produce truly different outcomes. Even the "system redesign" school of quality improvement in health care, as far as I can see, is actually talking about fairly small changes in how health care is practiced (hand washing, full draping for central lines) rather than fundamental changes in staffing, allocation of resources, and supporting infrastructure. At the end of the day, I don't see how we can get real change unless we spend as much time and money on quality improvement as we do on acquiring new technology in health care. It is just as—or maybe more-- important.

So what connection does this issue have to the health of older adults? Remember, older adults are THE MAJOR consumers of health care. They already constitute 50 percent of hospital occupancy and 35 percent of discharges despite only being 13 percent of the population. Moreover, because of the complexity of their medical regimes and their reduced physiological reserve (and probably inadequate training in geriatric care throughout the health professions), older adults are particularly likely to be the victims of errors and to suffer harm because of it.

But don't take my word for it. I asked Dr. Landrigan about the effects of age in his results, and he was kind enough to write back:

Dear Chris,

In response to your question, we went back and ran the age-based rates of harm. Per our hospital-based (internal) reviews:
The harm rate (per 100 admissions) for <65 was: 21.9 (13.0 preventable)
The harm rate (per 100 admissions) for 65+ was: 28.6 (19.1 preventable)

This translates into a 31% increased relative risk for older adults vs. younger for any harm, and a 47% increased relative risk of a preventable harm, just as you had hypothesized. Please let me know if I can provide anything further. Happy Holidays!

Chris

I think there is now clear and compelling evidence to argue that age is as much subject to disparities in care as race and gender and deserves every bit as much attention at a national level. To address these disparities, hospitals (and the entire health system) need to value geriatric care expertise in all members of the workforce. Hospitals should demand continuing education in geriatric care from all who provide care within their facilities and they should use their influence on professional schools to ensure that graduates meet minimum competencies in geriatrics (links to competencies in nursing, medicine, and social work). Efforts such as NICHE, ACE and its descendents, and HELP should be top priorities for responsible institutions looking to reduce these disparities.