Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT, a number-needed-to-treat tool to communicate benefit and harm.
Last time, boys and girls, we were talking about a number of reasons that medicine has made some progress in the past 30 years. Now, for all of you who won't believe a 32-year-old, some data.
You see mortality dropping if you look at any number of diseases that we were taught have a high mortality. Mortality-trends.org is a fantastic site that plots out death statistics for a number of countries since the 1950s, and there's a downward curve for most disease as you approach the 2000s. Cancer had some upticks in the 1970s-1990s, probably from increased diagnosis. But vascular disease, for example, had a mortality rate in men of 1,898 deaths per 100,000 men aged 60-69. Today, it's 526 per 100,000. Incredible.
A 2011 paper looked at improvements in “amenable mortality,” “the notion of ‘unnecessary untimely deaths,’ reflecting premature death from a set of conditions that should not occur in the presence of timely and effective health care.” (Health Policy 2011;103:47.) Developed countries have all shown advances in reducing “amenable mortality.” (Unfortunately but not surprisingly given our fragmented health care system, the United States placed last, with Greece just barely beating us.) We can also look at specific diseases.
“Never let the sun set on a bowel obstruction.” More and more patients are presenting older with adhesional bowel obstructions (because more patients overall are having surgeries), and Haukeland University Hospital in Norway, looking at 35 years of bowel obstructions, found lower mortality rates from 1961 to 1995. (Ann Surg 2000;231:529.)
Acute renal failure is frequently cited as having a 30-0 percent mortality, which, if you work clinically, you know to be untrue. A study looking at 1988-2002 showed mortality rates dropping from 37 to 23 percent. (J Am Soc Nephrol 2006;17:1143.) A smaller gain was seen in patients with acute renal failure requiring dialysis, again despite an increase in its incidence. I'm sure there's some degree of screening and documentation bias in all of these studies, unfortunately.
Even the tried-and-true STEMI is decreasing in incidence now that we have invested in thousands of cath labs. STEMI mortality, however, seems to be holding steady. So let's at least take a little peek at the data. And a few further thoughts about why.
Better care. We now know more about just how important time is in a number of highly morbid conditions, such as trauma and sepsis, and we have set up protocols to attempt to standardize care.
Better education, training, and standards. I'll be the first to question a number of the medications in the ACLS algorithm, but overall, having some standard approach helps people at least know to do something instead of just panic. Ask a senior nurse what it was like prior to ACLS; doctors all had widely different approaches to codes, making them even less organized and probably interrupting high-quality CPR.
Better follow-up care. Medicine finally started to realize that the care doesn't stop when the patient is discharged if you want good outcomes. Many of the strides we're taking in stroke and cardiac care is because of physical therapy, rehab, education, and social services.
Better access to care. We hate EMTALA, but the fact that you can walk in and see one of us is probably really good for people's health; we can provide reminders about diabetes, hypertension, and smoking cessation; we can I&D abscesses early, and we can give people EpiPens for home use.
Better vaccines. Yes, unfortunately, we're seeing small upticks in some infectious diseases in parts of the country, but overall we've gone from a mortality rate of 0.25 percent in 1912 to 0.1 percent in 1962, with it obviously being even lower now.
I've been quite the optimist for the past 600 words, but I'd like to add a few realistic notes. First, patient expectations have increased dramatically because of our successes. We're now able to perform and offer less invasive surgeries to replace grandma's heart valve that otherwise would have killed her, and patients frequently think there is no end to our abilities. That we can prevent a demented person from getting more confused or getting pneumonias. That you can show up to an ED drinking for 30 years, coagulopathic and blood erupting from your mouth, and be saved. We all know that “modern” medicine has its limits. We should strive to push those limits when appropriate, but also be clear with patients and their families.
Secondly, I worry that the doctor-patient relationship and communication continues to suffer with all of our technological advances and better outcomes. All health care professionals are expected to do more and more with either the same or fewer resources, so it's easiest to cut out the most important (and time-consuming) part of the patient encounter: educating the patient and allowing him to ask questions. Add in multiple handoffs, and it's no wonder many patients had no idea who their doctor was during a hospital stay, what medicines they're supposed to be taking, or what tests were done.
Finally, our ultimate mortality rate still stands steadfast at 100 percent. What does that mean? Our patients are much more chronically ill than ever before, and this chronic illness takes a toll. Every new problem stresses the body, making the times that they are critically ill even more challenging. It's no longer just good old urosepsis, period, end of statement. It's now a patient with urosepsis with an ejection fraction of 20% on dabigatran for Afib with a GI bleed who missed dialysis three days ago and also just quit drinking.
They still end up dying of something even when people aren't dying of bowel obstructions or renal failure or STEMIs. It's the big three in my mind: infection, cancer, and heart disease.
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* Use Dr. Walker's medical calculator at www.mdcalc.com and his number-needed-to-treat tool at www.thennt.com.
* Follow Dr. Walker on Twitter.com/grahamwalker for daily thoughts on emergency medicine.
* Read all of Dr. Walker's past columns at http://bit.ly/WalkerEmergentology.
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