DISEASES AND DEATHS—A Statistical Survey of 40,130 Autopsies at the Los Angeles County General Hospital, 1918 to 1948—Part II

The 215,468 diagnoses recorded in 40,130 autopsies on patients treated at the Los Angeles County General Hospital during the 30 years between 1918 and 1948 were reviewed and tabulated. The primary causes of death as determined by the pathologists in these cases were recorded and the incidence of death from each disease in relation to the number of cases in which each occurred was computed. The age, sex and race distribution of patients examined postmortem and the incidence and fatality rates from various pathological conditions changed greatly during the period, owing to many factors, among them changes in elements of the population served by the hospital, an increasing incidence of older patients, and medical triumph over some formerly formidable diseases.     

A Pill for the Ill? Patients’ Reports of Their Experience of the Medical Encounter in the Treatment of Depression

Background

Starting in the 1960s, a broad-based patients’ rights movement began to question doctors’ paternalism and to demand disclosure of medical information, informed consent, and active participation by the individual in personal health care. According to scholars, these changes contributed to downplay the biomedical approach in favor of a more patient-oriented perspective. The Swedish non-profit organization Consumer Association for Medicines and Health (KILEN) has offered the possibility for consumers to report their perceptions and experiences from their use of medicines in order to strengthen consumer rights within the health care sector.

Methodology

In this paper, qualitative content analysis was used to analyze 181 KILEN consumer reports of adverse events from antidepressant medications in order to explore patients’ views of mental ill health symptoms and the doctor-patient interaction.

Principal Findings

Overall, the KILEN stories contained negative experiences of the patients’ medical encounters. Some reports indicated intense emotional outrage and strong feelings of abuse by the health care system. Many reports suggested that doctors and patients had very different accounts of the nature of the problems for which the patient was seeking help. Although patients sought help for problems like tiredness and sleeplessness (often with a personal crisis of some sort as a described cause), the treating doctor in most cases was exceptionally quick in both diagnosing depression and prescribing antidepressant treatment. When patients felt they were not being listened to, trust in the doctor was compromised. This was evident in the cases when the doctor tried to convince them to take part in medical treatment, sometimes by threatening to withdraw their sick-listing.

Conclusions

Overall, this study suggests that the dynamics happening in the medical encounter may still be highly affected by a medical dominance, instead of a patient-oriented perspective. This may contribute to a questionable medicalization and/or pharmaceuticalization of depression.     

Hospital Expenditure at the End-of-Life: What Are the Impacts of Health Status and Health Risks?

Background

It is important for health policy and expenditure projections to understand the relationship between age, death and expenditure on health care (HC). Research has shown that older age groups incur lower hospital costs than previously anticipated and that remaining time to death (TTD) was a much stronger indicator for expenditure than age. How health behaviour or risk factors impact on HC utilisation and costs at the end of life is relatively unknown. Smoking and Body Mass Index (BMI) have featured most prominently and mixed findings exist as to the exact nature of this association.

Methods

This paper considers the relationship between TTD, age and expenditure for inpatient care in the last 12 quarters of life; and introduces measures of health status and risks. A longitudinal dataset covering 35 years is utilised, including baseline survey data linked to hospital and death records. The effect of age, TTD and health indicators on expenditure for inpatient care is estimated using a two-part model.

Results

As individuals approach death costs increase. This effect is highly significant (p<0.01) from the last until the 8th quarter before death and influenced by age. Statistically significant effects on costs were found for: smoking status, systolic blood pressure and lung function (FEV1). On average, smokers incurred lower quarterly costs in their last 12 quarters of life than non-smokers (~7%). Participants’ BMI at baseline did show a negative association with probability of HC utilisation however this effect disappeared when costs were estimated.

Conclusions

Health risk measures obtained at baseline provide a good indication of individuals’ probability of needing medical attention later in life and incurring costs, despite the small size of the effect. Utilising a linked dataset, where such measures are available can add substantially to our ability to explain the relationship between TTD and costs.     

DISEASES AND DEATHS—A Summary of Data from the Los Angeles County General Hospital, 1918 to 1948—Part I

Classification of the 2,557,035 diagnoses made in 1,168,139 different patients at the Los Angeles County General Hospital in the period 1918-48 has been compiled according to the new International List of Causes of Diseases and Death. Similar tabulation of the 377,776 diagnoses made in the 112,409 patients who died while in the hospital reflects the fatality rates associated with these diagnoses. Striking differences are shown in the incidence and fatality rates in the various conditions and great changes have occurred in both during this time. Defects and sources of error in these data are recognized, but they offer a wealth of valuable material for further study and interpretation.