U.S. must emphasize healthcare delivery, not just basic and clinical science research

Since 1955, the average American life expectancy has increased from 69 to 78 years. Many terminal cancers are now curable, AIDS has become a manageable chronic illness, and some patients can now go home with mechanical hearts that allow them to live with cardiovascular disease that was once universally fatal. The United States is more productive in biomedical research than the entire European Union. Indeed, the entire world looks toward the United States for major breakthroughs in medical research.

Yet this same American medical system leaves surgical instruments in patients, overdoses children with blood thinner medications, operates on the wrong side of the body, gives patients appropriate therapies only 50 percent of the time, and kills nearly 100,000 people per year from preventable errors. Perhaps most disturbing, a recent Commonwealth Fund Report ranked the United States healthcare system dead last among other industrialized nations in terms of quality, access, efficiency, equity and outcomes. Despite these poor outcomes, our median per capita expenditure for hospital services and drugs is three times larger than the 29 other countries that are part of the Organization for Economic Co-operation and Development (OECD). How can this be?

I believe this dichotomy is the result of our national failure to view the delivery of healthcare as a science. The majority of federal research funding supports what is often considered “biomedical science” — principally efforts to understand disease biology and identify promising new therapies for a variety of diseases.  Efforts to understand how to deliver those complex therapies safely and effectively are underfunded. For every dollar the federal government spends on traditional biomedical research, it spends a penny on research to ensure patients actually receive the interventions identified through biomedical research. Given this imbalance, it is understandable, perhaps predictable, that the U.S. has some of the best basic and clinical science research, yet the worst patient health outcomes in the industrialized world. To be certain we need to increase our support for traditional biomedical research. At the same time, patients and other stakeholders pay a substantial price for this myopic view of biomedical research. We need to ensure that we continue to identify effective therapies and make sure we use them safely and effectively.

There are examples of significant benefit from research aimed at ensuring patients receive evidence-based interventions. In a 2003 project funded in part by the Agency for Health Care Research and Quality (AHRQ), a research team from Johns Hopkins partnered with the Michigan Health & Hospital Association and 127 Michigan intensive care units (ICUs) to eliminate catheter-related blood stream infections (CRBSI) throughout the state. These catheters are large intravenous devices used in ICU patients to delivery important medications and monitor heart function. Although life-saving, these catheters can also cause harm with introducing blood stream infections in critically ill patients. Using guidelines from the Centers for Disease Control and Prevention (CDC), the program to eliminate these hospital-acquired infections had been developed and implemented at Johns Hopkins, where it lead to substantial reduction in these infections. Our team wanted to replicate the Hopkins results across an entire state.

The results of this project were breathtaking. They were published in the New England Journal of Medicine and later described in The New Yorker. Within three months of implementing our program, which included simple interventions like using a checklist to ensure doctors followed recommended practices, these infections were nearly eliminated. More than 50 percent of participating ICUs reduced their rate of catheter-related blood stream infections to zero, and that rate has persisted for four years. The overall rate of these infections was reduced by two-thirds. If implemented nationally, this program could substantially reduce the 28,000 deaths and $3 billion in excess costs attributed to these preventable hospital-acquired infections.

Individual states, including California and Ohio, are seeking funding to replicate the Michigan project. In addition, clinicians in Michigan want to develop a program to eliminate two very serious healthcare-acquired infections that are becoming an increasingly common and expensive problem in the U.S. health care system and a growing concern with the public, methicillin resistant staphylococcus aureus (MRSA), and vancomycin-resistant enterococcus (VRE). These bacteria are among the most common healthcare-acquired infections that affect one in 10 patients, kill approximately 90,000 individuals, and cost between $5 billion and $11 billion annually in the U.S.

Many, although not all, of these infections are preventable by the use of known interventions. Most of these infections could likely be prevented if we invested in ways to identify and implement effective preventative therapies. Yet, as a country, there is neither funding nor an infrastructure to create and implement such programs. To improve the ranking of our healthcare system from dead last among industrialized nations, there is an urgent need for such programs.

Why are efforts to improve the delivery of healthcare and prevent medical errors not a national funding priority? If patients are to receive the full benefits of our national investment in biomedical research, we must invest in studies directly aimed at understanding how to efficiently and effectively ensure that patients receive the beneficial therapies discovered by biomedical research. And the federal government should lead the way.

Pronovost is professor and director, Quality and Safety Research Group; medical director, Center for Innovations in Quality Patient Care, Johns Hopkins University School of Medicine; anesthesiologist and intensive-care physician, The Johns Hopkins Hospital; and professor in the School of Medicine and the School of Public Health at Johns Hopkins University.