Arnold Kling  

Health Care Safety

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Alex Tabarrok writes,

I consider a 1% chance of death to be very risky, perhaps worthwhile for some morbidly obese people but when 1 in every 100 patients doesn't make it off the table that is not good odds.

What I find most interesting, however, is that I don't think that any drug, even one with net benefits, could pass FDA trials with a mortality risk of 1%.

He is referring to bariatric surgery for obesity.

I think this is a very important point. We accept high risk when we go to a hospital at all. A paper from the Centers for Disease Control mentions (on p. 7)

Hospital-acquired infections from all causes are estimated to cause >90,000 deaths per year in the United States and are the sixth leading cause of death nationally.

The public wants to think in black and white terms. Something is "safe" (going to a hospital) or "unsafe" (taking Vioxx). The fact that in statistical terms the hospital visit is much more dangerous than the drug is something that is beyond people's capability to grasp, because they cannot think in terms of the gray area of probability.

UPDATE: lots of good pushback in the comments.

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COMMENTS (9 to date)
James from Pittsburgh writes:

I think there's two other related effects here that account for the difference in how the public evaluates the risk.

(1) People underestimate the potential hazard of going to the hospital the same way they might underestimate the risks involved in driving. I think most people have been to the hospital at some point and come back fine. Therefore, we let our own personal experience define our expectation of risk. Most people probably aren't on Vioxx, so hearing about the risks here leads us to overestimate the risk of Vioxx.

This leads to my next point...

(2) To the media, stories about prescription drugs being "risky" are probably a much easier sell than one about hospitals being risky. After all a prescription drug (such as Vioxx) has a national market and strong brand recognition. St. Mary's Hypothetical Hospital of Pittsburgh, though, will only have a regional brand. So due to their own recognizability prescription are just easier targets.

Anyway, that's my $0.02.

Phil writes:

Also, a hospital stay has a finite timeframe for risk. You go in, you have surgery, you go home. If you make it home and recover, the risk is over and done with. You beat the odds!

But a drug like Vioxx, you take it indefinitely. Not only is there never a point where you know you "won," but you have the feeling that your risk is getting higher and higher the longer you take the drug. You are reminded of the risk every time you take your daily dose, and the feeling of unease never goes away.

Even if the sum total of all the Vioxx risk is much lower (discounted for time, or not) than the surgery risk, the "mental anguish" factor is higher.

I think the same thing is going on with secondhand smoke panic. The idea that something might be killing you slowly, without you being aware of it, is very worrisome to some people. Telling them the true probability is very low doesn't help very much.

Buzzcut writes:

You guys have it all wrong.

Vioxx is the poster child of the conspiracy by the media-legal complex to profit at all of our expenses.

The Vioxx case was a blockbuster for the lawyers. They made gajillions of dollars.

They don't have that kind of income opportunity with hospitals. No individual hospital has that kind of cash, and the lawyers can't start a class action against all hospitals.

Vioxx was a blockbuster, and as a result was a target for lawyers to make the killing of a lifetime.

dave smith writes:

People should be willing to take a larger risk going to the hospitial since usually there are fewer substitutes. In other words, the marginal benefit of going to the hospitial when I need to go is greater than the margainl benefit of taking vioxx.

robd writes:

It is all a matter of cost against benefits.
In some cases a 1 in 100 chance of dying from treatment would be your best bet.

Lord writes:

Don't forget about the risk of not going to the hospital. That is likely sizable in comparison, while the risk of not taking a drug is probably also very low.

MD writes:

As far as the whole 'Hospital Acquired Infection and death' business, you, as smart econ types, should know to read between the lines on these numbers.

So when some old guy with a bad heart, lung cancer, colon cancer, failing kidneys, and a few strokes under his belt goes to the hospital for treatment of any of the above, and his frail, weak immune system lets an infection take over, and he dies of sepsis, it's a 'hospital acquired infection'. Now, is it really the infection that killed him? Think of it as cause of death and proximate cause of death. Yeah, the infection finished him off...but something had to finish him off, and it's because he had so many other things wrong with him that his luck finally ran out. It's like saying the last guy to cross home plate was entirely responsible for the Red Sox winning the series...yeah, he had the last hurrah, but it was a lot of individual events of a 162-game season and a few playoff series that got them to that point.

9160 writes:

Usually when people are deciding to take a medication they choose to do it because it is either the easier or less expensive solution to their issue. I do not believe that they are choosing the medicine because it seems safer than going to a hospital. In fact, the majority of people would probably rather go to the hospital and try to permanently solve the issue than go through a life long cycle of taking a medication everyday. Yes, there may be a large amount of hospital-acquired deaths every year, but I am positive that they are not all due to just simple infections. Some of the people who have died from these hospital-acquired infections did not die solely because of the infection in itself. The infection usually assists in many other health issues that the person is dealing with at the time.

Dr. T writes:

It is apparent to me that Alex Taborrok has never faced a serious medical problem. There are situations where doctors would LOVE to have a 1% operative mortality rate. My daughter has a progressive liver disease that may lead to liver failure. Liver transplants have a 25% mortality rate. But, liver failure has a 100% mortality rate. Not a tough choice.

Morbid obesity (where a person weighs more than twice his desirable weight) has a high annual mortality rate, a nearly 100% morbidity rate, and large negative effects on quality of life. For someone in this situation, a 1% operative mortality rate doesn't seem too risky.

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