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July/August 2014
Adverse Medical Events Prevalent With Medicare Researchers have found that nearly 20% of older adults who participated in a recent study experienced what the lead researcher referred to as an adverse medical event, or care that is required as the result of medical care itself, over and above the existing conditions. “It’s really much higher than that,” says Mary W. Carter, PhD, gerontology program director at Towson University in Maryland. She explains that the roughly 12,500 Medicare beneficiaries included in the study were followed for five-year periods between 1998 and 2005. As a comparison, a person’s risk of experiencing a car accident would be much higher in a lifetime than in a five-year period, she says. “Because older adults access the system so frequently, their lifetime risk is much higher,” she says. “That’s what the data suggest.” Mortality rates also nearly doubled for patients who suffered adverse medical events, Carter explains. There was a 28% death rate during the study period among patients who experienced an adverse event compared with 15% for those who didn’t. Examples of adverse medical events include a device failure, such as a pacemaker; an infection following a hospital stay; a reaction to medication that perhaps should have been anticipated; or a perforation during surgery. Since most previous research on adverse medical events has focused on hospital settings, Carter and her colleagues looked instead at adverse events across all medical settings that are reimbursed through Medicare, including outpatient and in-home care as well as nursing homes and physicians’ offices. Focusing across medical settings “more closely reflect(s) patterns of health care service use by older adults with public health implications in terms of ongoing patient safety concerns,” according to the report, which appeared in the May issue of Injury Prevention. Indeed, more than 60% of adverse events recorded in the study occurred outside of hospitals. Carter says she suspects that percentage reflects both a health care trend toward outpatient care and an increased reliance on pharmaceutical management of diseases. As people are living longer, more people aged 85 and older are taking multiple medications, and it is increasingly difficult to manage patients across medical practices, she says. Impact on Costs But for the 19% who suffered at least one adverse medical event, Medicare expenses spiked an average of 926% during or just after the event. Adjustments for socioeconomic status and overall health still yielded a 744% increase, on average, in Medicare expenses following an adverse event. In the months following the event, those expenses remained more than 250% higher than the expenses for those who never suffered an adverse event. In short, the expenses never returned to the level at which they may have been had the event not occurred, Carter says. All of the study participants were over the age of 65, with the majority aged 70 and older. Nearly 60% were women, and just more than 50% were married. Nearly one-third reported living alone. Core data came from the Medicare Current Beneficiary Survey, which is conducted by the Centers for Medicare & Medicaid Services and includes a nationally representative sample of all Medicare beneficiaries nationwide enrolled in the traditional Medicare program. Carter explains that Medicare claims reports include codes specific to adverse medical events. She and her colleagues restricted their research to more severe events, for example, those beyond headache medications that were not well tolerated. “We had to see an adverse event on multiple claims to ensure we were taking a conservative approach,” she says. “We set a threshold of seriousness to make sure we were looking only at those cases where the adverse event also was affecting health or physical functioning in some way.” Affected Patients Those likely to suffer an adverse medical event also were more likely to have a disability limiting daily activity, and those who described their own health as poor to fair (as opposed to good or excellent) at the outset of the study had a 32% higher risk of experiencing an adverse medical event. Carter says men, blacks, and the older members among the study participants also were more likely to experience adverse medical events. Carter says the study does not make a distinction between adverse medical events that reflect an error on the part of an individual or the system and those that don’t. “We’re not trying to vilify anyone or point to specific quality problems,” she says. But the data do suggest there are opportunities to better coordinate the transition of care among providers, she says. “Even if we can’t prevent the adverse event, we should have better communication and be able to intervene more quickly so the total burden of the event is mitigated,” she says. Proactive Approach While the rates of adverse events are unacceptable, Katz says the bigger solution is to make lifestyle changes that keep people healthy. “People who never develop heart disease won’t ever need treatment,” he says, explaining that through lifestyle choices, people can avoid the chronic conditions that require medical intervention. Two decades of evidence show that lifestyle changes can eliminate most of the chronic medical conditions that require medical intervention, Katz says. Specifically, eating well, staying active, and not smoking can reduce the risk of heart disease, stroke, cancer, and diabetes by nearly 80%, he says. Add to those lifestyle choices sleeping well, managing stress, and maintaining connections with other people and the risk of all chronic diseases, including cancer and dementia, drops by 80% or more. Katz acknowledges that achieving some of these goals, such as getting plenty of sleep, can be easier said than done, especially in a culture that does not encourage optimum health. “When cultures make these things a priority, it’s no longer quite so hard to do,” he says. Mediterranean and Asian cultures that promote what Katz identified as the six factors contributing to a healthy life—a diet based on plants and healthful fats, exercise, not smoking, reducing stress, sleeping well, and a strong sense of community—generally are populated by people who live long full lives with minimal chronic diseases. “The power of this is incredible,” he says. “If we could get minimally three and ideally six of those factors right, we would significantly reduce our rates of chronic diseases. In the short term, Carter recommends that patients ask more questions about their treatment, especially if changes in health status have occurred. Any time new treatment is introduced, she says there is a greater risk for something to go wrong. “There should be more opportunities for patients to talk with their medical providers and understand what [the changes] mean for their care,” she says. She also emphasizes the need for the health care industry to focus on ensuring coordination of patient care from one provider to another. “Communication alone so each provider is aware of the others’ treatment choices can reduce a patient’s risk of an adverse event,” she says. — Jennifer Anderson is a freelance health and science writer based in Falls Church, Virginia.
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