Concept of Iatrogenic disease
Iatrogenic harm ranks as the sixth highest public health problem in the developed world, worldwide accounting for as many as 10,000 deaths each and every day (cf. 8,000 HIV/AIDS; 3,000 road traffic accidents).
Perceptions of risk, and of what constitutes an appropriate degree of safety, vary considerably—and this depends also on the context. Think of these in terms of the patient related risks e.g., surgery on a patient with heart failure, investigation- or treatment-related risks, and individual healthcare practitioner and healthcare system risks.
Acceptability of risk in health relates to a balance between the potential for harm; the likelihood of doing good; and the choices available at the time. That is, the doctor and the patient together are always having to weigh up the. risks and benefits of any option (and comparing them to other options).
Adverse outcomes in medicine
Medical records suggest that approximately 10% of admissions to acute care hospitals are associated with an adverse event; some half of these are the cause of admission and the other half occur during the index admission. One in 100 GP encounters involves an adverse event. Prior to 2000, the US, UK, and Australia each spent about $1 a week per person (5% of their Healthcare budget) on treating adverse events, and another 5% in indirect costs—loss earnings, ongoing care, and including 1-2% on the tort system.
System failure v individual failure
The ‘Swiss Cheese” model of error prevention assumes that a large number of checks and balances (the cheese slices) in place to prevent errors, but each of them is imperfect (the holes in the slices)—it usually takes a number of system failures for an adverse outcome to occur. But, in fact, inadequate staffing, overwork, faulty procedures can (and sometimes do) align to produce errors.
Considerations include:
- How to collect and/or assess necessary information and how various components interrelate
- How to respond appropriately to things that go wrong
- How to develop/apply effective strategies for preventing similar problems in the future—i.e., error tolerant systems within which operate collective effort of individual HCPs and patients. It is a truism that substantial advances made in healthcare lie mainly in changes driven and maintained by individuals.
“Cost” of health care–State/National Models for Funding HealthCare
What percentage of state funding is ideal? This depends on perceptions of social responsibility and efficiency. Most countries have a mixture of:
- Fee for Service
- Capitation
- Full state funding
- Insurance-funded Managed Care
Australia’s Universal Health Care (Medicare) System with high quality outcomes and GP as ‘gatekeeper’; allows for additional payment for special services. (cf. UK ~ except payment by capitation; US expensive Managed care system; Malaysia employer-based clinics). One way of allocating resources is by ranking healthcare interventions according to their cost per quality adjusted life year (QALY) – evaluating cost-effectiveness of medical treatment in defined group of patients e.g., PBS drugs. Consider QALY and the cost of some of the procedures used in medicine: Nevertheless, growing interest in securing more efficient allocation of resources between interventions that affect human health – evidence emerging that enormous disparities in cost per life-year saved and cost per death averted across interventions.
Hospital/ Organisation
Funding is now based on some measure of activity, such as the number of conditions managed, or interventions undertaken—these “Diagnostic-Related Groups” (DRGs) are coded on discharge/death for some 10,000 International Classification of Disease (ICD) codes.
Diagnostic-Related Groups (DRGs): Provide clinically meaningful way of relating number and type of patients treated in a hospital (that is, its Casemix) to the resources required by the hospital. Each DRG represents class of patients with similar conditions (based on ICD-10) requiring similar hospital services – important factors include principal diagnoses, procedure/s, length of stay, cost weights
The ICD-10 classification
A disease classification based on WHO’s publication A new Australian classification of procedures based on the Medicare Benefits Schedule (MBS), sometimes referred to as MBS-Extended, and Australian Coding Standards for the selection of disease and procedure codes.
Spend $1M to improve health outcomes and see that will not make much difference overall. Try $2m – result the same. What if $20M? – Even this unlikely to have a major positive benefit. Spending more does not necessarily improve outcomes for patients e.g. US spend 3 x NZ on healthcare but has higher infant mortality: appropriateness; efficiency; distribution between public health and primary, secondary, and tertiary care.
Consider also the role of allied health care and community services (HACC) etc.
Figures in this section draw on Runciman, W., Merry, A. and Walton, M. (2007) Safety and Ethics in Healthcare: A Guide to Getting it Right. Aldershot: Ashgate.
Case study: Obesity and Type 2 Diabetes in Aboriginal and Torres Strait Islander Communities
Aboriginal and Torres Strait Islander Australians experience disproportionately high rates of overweight, obesity, and type 2 diabetes compared with the non-Indigenous population.¹ Understanding why matters, because the explanation a clinician or policymaker reaches for shapes what they think should be done about it — and history shows that the wrong explanation causes real harm.
A narrative sometimes advanced — and worth naming explicitly so it can be examined rather than absorbed — runs roughly as follows: that Aboriginal people simply choose Western foods (chips, soft drinks, alcohol) they are “not genetically programmed” for, and are personally lazy or indifferent about their health. This account locates the problem entirely within individual biology and behaviour, and its policy conclusion is bleak: that higher rates of illness and earlier death are simply “the Aborigine’s problem,” with little to be done. This narrative has been widely and rightly criticised as both scientifically unsupported and harmful in practice — it individualises what is substantially a structural problem, and it has historically been used to justify withdrawing rather than investing in services.²
A more accurate account is a structural one. Colonisation, forced removal from land and traditional food systems, the intergenerational trauma of policies including the Stolen Generations, and ongoing socioeconomic disadvantage and systemic racism in health and other systems have profoundly shaped the food environments, health service access, and living conditions available to Aboriginal and Torres Strait Islander communities.³ Framed this way, elevated obesity and diabetes rates are a predictable consequence of the environments and constraints people have been placed within — not a matter of individual choice or genetics.
This is also why Aboriginal community-controlled health organisations and Aboriginal leadership in the design and delivery of health services consistently produce better outcomes than externally-imposed programs⁴ — an approach reflected in Australia’s Closing the Gap framework, which was itself redesigned in 2020 in partnership with the Coalition of Aboriginal and Torres Strait Islander Peak Organisations.⁵ For any clinician working with Aboriginal or Torres Strait Islander patients, this underlines a broader point: individual behaviour-change advice, given in isolation from an understanding of this context, is unlikely to be either respectful or effective.
References
- Australian Institute of Health and Welfare (2024) Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW.
- Anderson, I., Robson, B., Connolly, M. et al. (2016) ‘Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study’, The Lancet, 388(10040), pp. 131–157.
- Paradies, Y. (2016) ‘Colonisation, racism and indigenous health’, Journal of Population Research, 33, pp. 83–96.
- Panaretto, K.S., Wenitong, M., Button, S. and Ring, I.T. (2014) ‘Aboriginal community controlled health services: leading the way in primary care’, Medical Journal of Australia, 200(11), pp. 649–652.
- Coalition of Peaks and Australian Governments (2020) National Agreement on Closing the Gap.