Knight Steel

Iatrogenic illness on a general medical service at a university hospital.

We found that 36% of 815 consecutive patients on a general medical service of a university hospital had an iatrogenic illness. In 9% of all persons admitted, the incident was considered major in that it threatened life or produced considerable disability. In 2% of the 815 patients, the iatrogenic illness was believed to contribute to the death of the patient. Exposure to drugs was a particularly important factor in determining which patients had complications. Given the increasing number and complexity of diagnostic procedures and therapeutic agents, monitoring of untoward events is essential, and attention should be paid to educational efforts to reduce the risks of iatrogenic illness.

Iatrogenic illness on a general medical service at a university hospital

We found that 36% of 815 consecutive patients on a general medical service of a university hospital had an iatrogenic illness. In 9% of all persons admitted, the incident was considered major in that it threatened life or produced considerable disability. In 2% of the 815 patients, the iatrogenic illness was believed to contribute to the death of the patient. Exposure to drugs was a particularly important factor in determining which patients had complications. Given the increasing number and complexity of diagnostic procedures and therapeutic agents, monitoring of untoward events is essential, and attention should be paid to educational efforts to reduce the risks of iatrogenic illness.

Referral of Patients from Long‐term to Acute‐care Facilities

Medical care available to residents of nursing homes and chronic‐care hospitals was assessed by studying transfers of such persons to the emergency room of an acute‐care hospital. One hundred patients transferred from nursing homes and 16 patients transferred from chronic‐care hospitals were compared with 338 elderly patients from home (control group). Elevated temperature (≥102°F) was found in 17.3 per cent of nursing home patients and 30.0 per cent of chronic‐case hospital patients, compared with 1.8 per cent of controls (P < .05); mental status abnormalities were found in 66.1 per cent of patients from nursing homes and in 90.9 per cent of those from chronic‐care hospitals, compared with 36.2 per cent of controls (P < .025). In addition, patients from chronic‐care hospitals, but not those from nursing homes, often showed substantial abnormalities of blood pressure and pulse. Thus, the patients from nursing homes tended to be slightly sicker than controls, and those from chronic‐care hospitals considerably sicker. The probability of requiring admission to the hospital was the same for residents of nursing homes and persons living at home (44.0 per cent and 43.2 per cent, respectively), but was higher for persons from chronic‐care hospitals (81.3 per cent, P < .005).

Iatrogenic Disease on a Medical Service

Iatrogenic disease is a subject rarely received with much enthusiasm by a medical audience. Let me address that concern at once by sharing with you the results of an investigation, “Medical Insurance Feasibility Study” by Mills, who is both a doctor and a lawyer.’ He tabulated the incidence of “potentially compensable events” (PCEs) in a sample of 20,864 hospital records in California in 1974. Slightly less than 5 per cent of all charts documented such a potentially compensable event. It is noteworthy that patients over 65 years of age had a significantly higher rate of PCEs than those under 65. The author found, however, that less than 1 per cent of charts (about 17% of all PCEs) disclosed evidence of probable liability-and this in a state that is notoriously litigious. My discussion will not address the problem of what liability might conceivably accrue from a given action at a future date. Rather, it is my intent to consider iatrogenic disease in a systematic way with an eye to designing the means to minimize it. I am making no statement about the codbenefit ratio of an encounter with the health-care industry. I think, on the average, the benefits clearly outweigh the costs. My interest lies quite simply in minimizing the risks and maximizing the benefits. Although I will emphasize the importance of this subject to the care of the elderly, iatrogenic illness is of concern to all physicians who care for patients. With few exceptions, however, I will confine my remarks to phenomena that take place on a medical service, leaving aside consideration of the risks of surgery. Since Moser wrote about the illnesses of medical progress in 1956,2 the number and complexity of diagnostic endeavors has increased sharply, the number of pharmaceutical agents prescribed has risen yearly, and the patient population has aged significantly (and will, in all likelihood, continue to do so). As a point of reference, at University Hospital, Boston University Medical Center, about 50 per cent of patients admitted to the general medical service are at least 65 years of age. Thus large numbers of persons who have the diminished physio-

The First Certifying Examination in Geriatric Medicine

On April 22, 1988, the first Certifying Examination in Geriatric Medicine was administered jointly by the American Board of Internal Medicine and the American Board of Family Practice to 4,282 diplomates (ABIM = 2,202; ABFP = 2,080). This paper addresses both an analysis of the examination and the relationship between performance on that examination and a group of characteristics of the examinees, collected as part of the registration process. The pass rate was 56%. Performance on the examination was positively correlated with scores on the general certifying examinations and with training in geriatric medicine. Data provided by the candidates in an addendum to the application were also available for analysis and were used to derive correlations with groups of questions. The performance of candidates was positively correlated with seeing large numbers of elderly in hospitals, nursing homes, or home settings, working in a University Hospital, teaching and research, and the size of the community in which the candidate practiced. Physicians from long‐term care settings did exceptionally well. Working in a solo practice setting was negatively correlated with performance on the examination as was working in a for‐profit setting.

Physician-Directed Long-Term Home Health Care for the Elderly—A Century-Long Experience

F rom the considerable amount of literature on home care, it is absolutely clear that home care is preferred by almost all to any forms of institutional care, acute or chronic. This is true notwithstanding the fact that the definition of home care is extraordinarily vague. The term, at times, refers to the services provided by home health agencies organized over the past quarter of a century in response to Medicare legislation. Here it usually encompasses visiting nurse services with one or, infrequently, more than one other service. On other occasions, the term reflects the functions of a nonuniform group of health professionals ranging from podiatrists to the highly technically qualified personnel required for home dialysis. It is my intention to limit the term to physician-directed coordinated home care. Furthermore, and most importantly, the term, at times, refers to ongoing care over months or years to a chronically ill population while on other occasions the word is restricted to a posthospital period of varying length. In the real world of health care delivery, this distinction is of great importance as the purpose of home care must be defined before the appropriate payor of services can be determined. Before considering our expedence at University Hospital, Boston University Medical Center, which dates back at least a century, there are two other renowned home care programs which warrant commentary. The first, established at Montefiore Hospital

An Analysis of Types and Costs of Health Care Services Provided to an Elderly Inner-City Population

The challenge facing national policymakers is to provide health care that is comprehensive and cost-effective to our nations growing population of elderly people. A solution worthy of consideration is the use of health maintenance organizations (HMOs) in this capacity. An analysis of the services provided by a multidisciplinary health care system to 150 inner-city elderly, many of whom were “homebound,” reveals 1) this population is not homogeneous with respect to severity of disease and service utilization, and 2) a total mean cost per individual per year of

Hyperparathyroidism in the Elderly

2,021.34 covers: physician, nursing, and social service home visits; visiting nurse, homemaker, home health aide, occupational therapy and physical therapy services; outpatient, laboratory and medication costs. These findings suggest that while costs for those over 65 are many times the per capita costs of younger enrollees, these costs may be significantly less than the costs of institutional care. Further investigation of the costs of maintaining low-income inner-city old, as well as other elderly populations, at home is vital to planning for future long-term care.

Why Elderly Patients Refuse Hospitalization

A survey was made of the records of 40 patients aged 60 or older who were operated on at Boston University Medical Center over a 10‐year period for suspected primary hyperparathyroidism. Mild or “asymptomatic” presentation was virtually the rule, with many patients having become accustomed to some degree of decreased well‐being. The findings were compared with those in other reviews of the clinical manifestations of hyperparathyroidism, in both general and elderly populations of patients. Issues of screening for mild or asymptomatic disease, especially among the elderly, are discussed.

Book ReviewHealth in an Older Society

To identify important factors in the refusal of hospitalization by elderly patients, a study was conducted of 35 such “refusers” on the Home Medical Service (HMS) of University Hospital and a comparison group of 70 patients who accepted hospitalization. Data were collected from health care providers and patient records at entry and six weeks later. The two groups were compared on the basis of demographic factors, health care factors, medical condition, and outcomes. Reasons for refusal were most commonly related to a negative perception of the health care system or a passive acceptance of death. Refusers were significantly less ill than acceptors and did not change in health or functional status at follow‐up. The results suggest that refusal of hospitalization is most often related to interaction with the health care system and that less ill patients may have reasonable outcomes when treated at home.