While the United States comprises only 4.2% of the world’s population, as of 2015, it managed to consume ~30% of the world’s opioid painkillers (INCB, 2016; census.gov, 2017). This consumption has slowly emanated from the clinic into the hands of recreational users. Since 2013, fatal drug overdoses exceeded the number of fatal car accidents in the United States. Opioid overdoses alone account for 67.8% of those overdose deaths (drugabuse.gov, 2017). Unlike opioid problems of the past, more than 75% of this epidemic’s abusers began on prescription pills rather than on a street drug like heroin (Cicero et al., 2014; Muhuri et al., 2013; Jones et al., 2013). In the 10 years between 2006 and 2016, the death rate for drug overdose in the U.S. increased 72 percent to 19.8 deaths per 100,000 population (National Center for Health Statistics, 2017). While dramatic action can and should be taken to address this crisis, root cause analyses, critical incident analyses, and small changes to the systems-level core of the healthcare system may guide us to more efficient, effective, and elegant solutions to the country’s most pressing public health emergency.
History provides us with plenty of examples of ineffective healthcare systems that were changed by individuals or institutions engaging in root cause analysis. Root cause analysis (RCA) is a problem solving method that identifies the causes which, if removed from the problem-fault sequence, prevents the final undesirable outcome from recurring. This is in contrast to a causal factor, which affects an event’s outcome, but is not a root cause. A prime example of this method succeeding occured in the field of anaesthesiology in the later half of the 1900s. From 1948-1952, there were 4.1 anaesthesia-related deaths per every 10,000 surgical procedures. Ellison Pierce, president of the American Society of Anesthesiology at the time, turned to bioengineer Jeffrey Cooper, a human factors expert, to assess the situation. Mr. Cooper looked at the problem like an integrated but broken system as opposed to an isolated problem. This eventually resulted in a landmark paper: “Preventing Anesthesia Mishaps – A Human Factors Study” which found 82% of preventable mistakes at the time were due to human error; most of these errors usually involved inadequate training, fatigue, and poor communication. Instead of waiting for a massive technological breakthrough, basic checklists were recommended to improve care and lead to the modern anaesthetic mortality rate of <1 in 100,000 surgical procedures. This type of systems-level thinking and root cause analysis within our modern healthcare system could lead to dramatic improvements without the need for significant technological innovation. This begs the question: is this type of analysis done today? Unfortunately, it does not seem to be the case. While families and lawyers may end up doing systems-level thinking about each individual tragedy, most medical boards, researchers, and governments do not.
However, sometimes providing a narrow and specialized solution can mend a daunting problem without changing or even considering the whole system. For example, focused and innovative specialty care programs have been able to markedly improve upon the standard-of-care for certain patient populations, effectively leading by example, and providing a path that the rest of the medical community eventually begins to follow. As a case study, the Shouldice Hernia Centre in Canada demonstrated that a specialty care treatment model could lead to dramatically better outcomes. By harnessing a variety of tools and competitive advantages, including innovation (new surgical techniques), experience/specialization (a specific focus on only hernia repair), regulatory advantage (Canadian regulations), education/research (optimization of procedures and training), Shouldice achieved a recurrence rate of 1% for hernia repair versus the typical 10-15%, or a greater than 90% reduction in readmittance. Furthermore, Shouldice’s treatment is an outpatient program versus other hospitals that involved multiple days of inpatient recovery, further decreasing costs while improving efficacy versus the standard-of-care. Despite their relatively small size, Shouldice challenged and changed the world of medicine and should inspire the rest of the healthcare industry to specialize, zoom-in, and strive for superior patient outcomes.
By embracing lessons of the past and taking a market-driven approach to healthcare, medicine’s greatest modern challenges are soluble. With a focus on specialized care, root level analyses, systems-level thinking, and emerging technologies, Vitality is prepared to address this epidemic and bring about a new generation of care for the populations who need it the most.