Sunday, February 10, 2019

Do patients stop dying when doctors go on strike? Quality comes at a price

Dr KK Aggarwal

Last week I read a Lancet study, which said that 21 lakh people in low and middle-income nations die within 30 days post- surgery. Around 3.13 crore surgical procedures are performed worldwide each year. The number of post-operative deaths globally is 42 lakhs and 7.7% of these deaths occur within 30 days of surgery. 

This is a surprising amount of mortality, which occurs following elective surgery.

Post-surgery deaths are greater in number than what is attributed to any other cause of death globally, except ischemic heart disease and stroke. At present, around 4.8 billion people worldwide lack timely access to safe and affordable surgery. There is an annual unmet need for 143 million procedures in low- and middle-income countries. It is projected that an expansion of surgical services to address unmet need would increase total global deaths to 61 lakh annually.

The study took me back to 1976; it was my second year of MBBS.  In that year, in January, doctors in Los Angeles went on strike in protest over soaring medical malpractice insurance premiums. For five weeks, approximately 50% of doctors in the county reduced their practice and withheld care for anything but emergencies. Cunningham and colleagues found the strike actually prevented more deaths than it caused. Mortality declined steadily from week one (21 deaths/100,000 population) to weeks six (13) and seven (14), when mortality rates were lower than the averages of the previous five years. And, as soon as elective surgery resumed, there was a rise in deaths. There were 90 more deaths associated with surgery for the two weeks following the strike in 1976 (i.e. when doctors went back to work) than there had been during the same period in 1975.

The most comprehensive review of the medical impact of doctors' strikes was published in the journal Social Science and Medicine in 2008. A team led by Solveig Cunningham and Salim Yusuf at Emory and Georgetown Universities in the US and McMaster University in Canada, analyzed five physician strikes around the world, all between 1976 and 2003. Doctors withdrew their practice in the different strikes analyzed, from between 9 days and 17 weeks. All the different studies report population mortality either stays the same, or even decreases, during medical strikes. Not a single study found death rates increased during the weeks of the strikes, compared to other times. It was concluded “it's a fact that elective, or non-emergency surgery, tends to stop during a doctors' strike, which seems to be the key factor”.

But Gruber and Samuel Kleiner who analyzed the effects of nurses' strikes in hospitals on patient outcomes using nurses' strikes over the 1984 to 2004 period in New York Stat wrote in a paper entitled, "Do Strikes Kill? Evidence from New York State," that nurses' strikes increase in-hospital mortality by 19.4% and 30-day readmission by 6.5% for patients admitted during a strike. The authors, from MIT and Carnegie Mellon University, concluded that hospitals during nurses' strikes are providing a lower quality of patient care.

One of these five studies was an intriguing study, which analyzed changes in mortality by studying the Jerusalem Post's newspaper reports of funerals during another Jerusalem doctors' strike, this time between March and June of 2000. This one arose from the Israel Medical Association's conflict with the government's proposed wages. The hospitals in the area cancelled all elective admissions and surgeries, but kept emergency rooms and other vital departments, such as dialysis units and oncology departments, open. The funeral study found a decline in the number of funerals during the three months of the strike, compared with the same months of the previous three years. One burial society reported 93 funerals during one month of the strike (May 2000) compared with 153 in May 1999, 133 in May of 1998, and 139 in May 1997.

How can this be explained?

Firstly, is it the elective or non-emergency surgery, which is usually most affected in a doctor's strike responsible for the higher deaths? The answer is yes. You can stay in bed with a fractured leg for six months and live with a malunited leg throughout your life but if you like quality and start walking within few days you need to take a risk of 1-2% by getting an elective surgery.
Elective surgeries including anesthesia are not risk-free. Lowest risk is 0-1%, moderate risk is 1-5% and high risk is > 5%. Considering the number of surgeries in India, 1% will be a substantial number.

Sudden or unexpected death in otherwise low risk population is also responsible for most litigation.

In every elective surgery, the treating surgeon must define the chances of complications linked mortality during surgery and anesthesia and the hospitals facilities to manage complications if they occur.

The take home message is that no surgery can be said to be risk-free. No surgery can be called a 'minor' surgery. Failing to abide by the standards of quality and add to the mortality.

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

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