Monday, 23 January 2017

Doctors strikes and medical congresses = less mortality

At a doctors' strike in Israel in 2000, the gravediggers noticed that their workload diminished in areas where the doctors’ strike was on, while it remained unchanged in areas where doctors did not adhere. Judy Siegel-Itzkovich, scientific editor of the Jerusalem Post, in a letter called “Doctors' strike in Israel may be good for health”  attributed the phenomenon to the shutdown of the scheduled surgery, which probably brings improvements of certain ailments, but which, by itself, can lead to complications and mortality. A few years later, in “Doctors' strikes and mortality: a review”, a systematic review of 156 papers analyzing the mortality impact of several doctors' strikes around the world, shows that during the doctors’ strikes, the population mortality either remains unchanged or lowers, but it never rises. The authors of the paper, like the Jewish publisher, also think that the phenomenon is an indirect measurement of the surgical over activity so common in clinical practice that, curiously, is shown when the programmed activity ceases drastically during a certain period.

Along the same lines, a group of Harvard researchers have studied what happens to heart patients during the days of the specialty congresses:  "Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during National Cardiology Meetings". In the USA there are two major cardiologists’ conferences each year, the American Heart Association (AHA) and the American College of Cardiology (ACC), which summons between 10,000 and 20,000 attendees each year, depending on the year. The cited study is a retrospective study, published in JAMA Internal Medicine, which selected 8,570 Medicare beneficiaries who had been admitted for myocardial infarction, heart failure, or cardiac arrest in all US hospitals during the 82 days of AHA and ACC in the period 2002 to 2011. The data were compared with another selection of patients who had been hospitalized for the same causes on equivalent days of the weeks immediately before and after those of the congresses.

The impact of congresses on patient mortality

Results only in large university hospitals: a) Mortality (30 days after admission) from heart failure in high-risk patients: congressional days, 17.5% (CI 95%, 13.7%-21.2%) vs. normal days, 24.8% (CI 95%, 22.9%-26.6%), p<0.001; and b) Mortality (30 days) of high-risk patients admitted for cardiac arrest: congressional days, 59.1% (CI 95%, 51.4%-66.8%) vs. normal days, 69.4% (CI 95%, 66.2%-72.6%), p<0.01. In summary, in the large university hospitals, high-risk patients admitted during the days of congress for heart failure and cardiac arrest died less. In contrast, no differences were found in mortality for myocardial infarction at all risk levels, nor for heart failure or cardiac arrest in low risk patients. Neither was there any difference in the mortality of any diagnosis studied in non-university hospitals.

Impact of congresses on angioplasties

The adjusted rate of interventional angioplasties in university hospitals decreased during the days of congress, 20.8% vs 28.2%, p=0.2; and it was concluded that patients admitted for myocardial infarction, when the number of specialists is reduced, receive fewer interventions but, instead, this fact does not affect the specific mortality.

Medical strikes and congresses offer two quasi-experimental situations to identify the impact of medical over activity. In the first case, it is observed in the mortality associated with the scheduled surgery. In the second case, it is seen as in university hospitals, devoid of the most significant experts for a few days, the remaining teams are more likely to concentrate on the more effective actions, as demonstrated in the reduction of probably unnecessary angioplasties.

More difficult to interpret are the outcomes of mortality of high-risk patients with heart failure and the equivalents who have suffered cardiac arrest, but one must think that, given the critical situations of this group of patients, when the centres have all the care available, they are more inclined to perform heroic therapeutic actions, although the latter is only an assumption.

Jordi Varela

No comments:

Post a Comment