Editor’s note: This summary is based on “Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance” published in Mayo Clinic Proceedings.
Injuries caused unintentionally by medical treatments, including medical error, are unfortunately common. Case in point: research shows that medical error is the third leading cause of death worldwide.
Despite advances to reduce infections and injuries, which have saved money and lives, hospitals and the U.S. Centers for Medicare and Medicaid Services (CMS) are missing a chance for even greater impact.
In an article published in Mayo Clinic Proceedings, we argue that these challenges hospitals and CMS are encountering are reversible and potential solutions to the problem stem from simple health system redesign and payment reform.
The Complexity Bias Problem
Healthcare organizations often tend to overcomplicate the reduction of iatrogenic injuries- the medical term for injuries caused unintentionally by medical treatments- by breaking them down into many parts that address limited components of the greater problem. We call this “complexity bias.”
This sets up a scenario in which organizations may invest in separate initiatives to improve outcomes of infections, while failing to realize that individual outcomes have overlapping risk factors which remain unaddressed. In addition, medical directors with budget constraints often prioritize adoption of some high-return, low-risk tasks with simpler prevention guidelines (e.g. infection) over others due to resource scarcity, which results in overall improvement of performance.
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However, these actions fail to address the needs to prevent all harms, particularly those with more costly protocols that lack strong evidence (e.g. pressure injuries). Pressure injuries in particular are costly to prevent because the prevention protocol is labor intensive: it includes repositioning patients from side to side, managing incontinence issues, and risk-assessing all patients every day. These actions add up to a cost of about $100 per-patient per-day in the ICU. In comparison, some infection prevention protocols are only implemented on-demand at half the cost. Thus, hospitals seeking to reduce average rates of hospital-acquired conditions can invest in lower-cost prevention protocols to achieve overall rate reductions without investing in more costly protocols such as pressure injury prevention.
A better way to prevent all measures equally would explore factors that overlap between outcomes. Centering a prevention program around all risk domains and treating outcomes as events along a continuum of common risk factors – rather than as mutually exclusive, isolated events – could potentially address the needs of patients at risk.
Returning to the example of pressure injuries, there are three key domains to effectively manage risk: mobility, moisture and nutrition. Managing these areas could reduce risks of other types of medical error and improve patient outcomes overall. Thus, centering a prevention program around these domains—rather than just around pressure injury reduction—could address needs for patients at risk for most types of infections, falls, and other injuries.
Meanwhile, health systems should consider a top-down approach to prevention. To reduce complexity bias, CMS should consider rewarding health systems for good performance, rather than enforcing only punitive measures.
Ultimately, the existing model of prevention generates complexity bias that may not serve hospitals or patients well. A model that unites care teams in a common mission would reduce complexity bias. There are a number of incentives CMS could employ to help achieve this objective.
Read the full article at Mayo Clinic Proceedings.
Padula, W. V., Armstrong, D. G., & Goldman, D. P. (2022, February). Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. In Mayo Clinic Proceedings (Vol. 97, No. 2, pp. 221-224). Elsevier.