| MrPepper11 2004-12-25, 7:09 pm |
| New York Times
December 25, 2004
Program Coaxes Hospitals to See Treatments Under Their Noses
By GINA KOLATA
The federal government is now telling patients whether their local
hospitals are doing what they should.
For now, the effort involves three common and deadly afflictions of the
elderly - heart attacks, heart failure and pneumonia - and asks about
lifesaving treatments that everyone agrees should be given but that
hospitals and doctors often forget to give.
The expectation, though, is that this is just the beginning; other
diseases, other treatments and surgery are next. Within a few years,
individual doctors will be rated as well.
Using incentives like bonus pay and deterrents like public humiliation,
it is a bold new effort by the federal government, along with
organizations of hospitals, doctors, nurses, and health researchers, to
push providers to use proven remedies for common ailments.
And it is a response to a sobering reality: lifesaving treatments often
are forgotten while doctors and hospitals lavish patients with an
abundance of care, which can involve expensive procedures of
questionable value. The results are high costs, unnecessary medicine
and wasted opportunities to save lives and improve health.
Simple things can fall through the cracks.
"In some ways, it's kind of scary," said Dr. Peter Gross, the chief of
the department of internal medicine at Hackensack university Medical
Center in New Jersey. "The doctor today is much too busy and has too
much to remember."
The hospital ratings are being done by Medicare and posted on the
Internet (www.cms.hhs.gov/quality/hospital/).
And already, hospitals are responding, often with shock, when they
discover they have been forgetting some of the very treatments that can
make a difference between life and death, or sickness and health.
At Duke University's hospital, for example, when patients arrived short
of breath, feverish and suffering from pneumonia, their doctors
monitored their blood oxygen levels and put them on ventilators, if
necessary, to help them breathe.
But they forgot something: patients who were elderly or had a chronic
illness like emphysema or heart disease should have been given a
pneumonia vaccine to protect them against future bouts with bacterial
pneumonia, a major killer. None were.
All bacterial pneumonia patients should also get antibiotics within
four hours of admission. But at Duke, fewer than half did.
The doctors learned about their lapses when the hospital sent its data
to Medicare. And they were aghast. They had neglected - in most cases
simply forgotten - the very simple treatments that can make the biggest
difference in how patients feel or how long they live.
"It's like the Elisabeth K=FCbler-Ross stages of grief," said Dr. Robert
Califf, a professor of medicine at Duke. "First you're in shock, then
denial, and then you gradually come to terms with what needs to be
done."
Now, Dr. Califf said, the hospital is scrambling to make sure such
treatments are not neglected again.
Department of Veterans Affairs doctors had also been forgetting
treatments like the pneumonia vaccine, said Dr. Jonathan Perlin, the
agency's acting under secretary for health. "Everyone knows who should
get the vaccine," Dr. Perlin said. "They can recite chapter and verse."
But not long ago, only 30 percent of V.A. patients who should get the
vaccine received it (the national average is 50 percent). The rude
awakening came when the department showed individual teams of doctors
and individual clinics and hospitals how often they were vaccinating
and how their rates compared with those of other medical teams. "It's
pretty revealing to have the data," Dr. Perlin said. "Absent the data,
you think you are doing a pretty good job."
Now 90 percent of V.A. patients who should get the vaccine do.
"By increasing the rate of pneumonia vaccination just for patients with
emphysema, the V.A. saved 6,000 lives," Dr. Perlin said.
The same strategy worked with beta blockers - drugs, costing pennies a
day, that should be given to nearly all heart attack patients within 24
hours of arriving at the hospital and should be prescribed when they
leave. Nationwide, less than half who need these drugs get them. Yet
beta blockers, which slow the heart rate, can prevent hospitalizations,
prolong lives and save more than $6,000 per patient in hospitalization
over five years.
The Department of Veterans Affairs has gone from giving beta blockers
to about 60 percent of its heart attack patients to giving them to 98
percent.
Sometimes, disclosure of lapses in one area can elicit changes in a
hospital's entire system, saving patients' lives across the board.
That happened when Duke researchers asked 315 hospitals for data on
nine drugs that everyone agrees should be provided to heart attack
patients.
For example, the hospitals were asked how often their heart attack
patients got aspirin when they arrived (that alone can cut the death
rate by 23 percent). When they were discharged, did they also get a
statin to lower cholesterol levels? Nearly all should, with the
exception of patients who have had a bad reaction to a statin and those
rare patients with very low cholesterol levels. Did they get a beta
blocker?
Once hospitals learned their score, it was up to them what to do. Over
the next year, ones that improved in these measures saw their patient
mortality from all causes fall by 40 percent. Those whose compliance
scores did not change had no change in their mortality rate, and those
whose performance fell had increases in their mortality rates.
"Those are the most remarkable data I have ever seen," said Dr. Eric
Peterson, the Duke researcher who directed the study and has reported
on it at medical meetings.
The new efforts to improve care came about because the time was right,
health care researchers say. "It's really an accumulation of scientific
knowledge about what quality means," Dr. Califf said. And there was a
growing realization that quality care was not always being provided.
But when it comes to improving care, there is always the contentious
issue of deciding what is good medicine.
"Most of what we do has a modest effect, and that means, by the very
nature of the effects, that you can't tell whether what you are doing
is effective unless you do a study," Dr. Califf said.
But that takes time, money, and often thousands or tens of thousands of
patients. In most cases, such studies have not been done.
Dr. Califf and others cited bed sores as an example. The nation spends
billions of dollars a year on special bandages and beds and treatments.
"None of these is proven," Dr. Califf said. "But if you are making a
ton of money being reimbursed by Medicare, the last thing you want to
do is put your treatment to a test."
So, at Medicare, administrators decided to focus on just a few
treatments at first, for a few common diseases - pneumonia, heart
attacks and heart failure - where there was little controversy about
whether those treatments worked and an abundance of data showing that
doctors and hospitals often did not provide them.
"We made an initial decision, which was very political," said Dr.
Stephen Jencks, Medicare's director of quality coordination. "We were
going after things where there was complete agreement that a service
was not being provided."
They are only a start. "Almost everyone would agree they are a very
narrow slice of the health care pie."
So the agency asked the nation's hospitals to report how well they did
in providing these treatments if they wanted this year's cost-of-living
increase in Medicare payments. Ninety-eight percent complied.
Medicare expects that now that the hospitals' performances are public,
many will try to improve. "People will begin to feel a little awkward
if everyone else is doing better and they're not," Dr. Jencks said.
The next step, Dr. Jencks said, is "aligning payment with what you want
people to do."
To that end, Medicare has a pilot program to pay hospitals for
improving on a number of quality measures, including mortality rates
and readmission rates for hip or knee surgery. Hospitals in the top 10
percent for a given condition, for example, will be paid an extra 2
percent. The agency will pay less if performance deteriorates. The
project involves 278 hospitals affiliated with Premier, a nationwide
organization of nonprofit hospitals.
The new initiatives have one thing in common - they abandoned the
traditional assumption that if doctors know what works, they will
provide it.
Doctors do know what works, said Dr. Steven M. Asch, a health care
researcher at the V.A. Greater Los Angeles Health Care System and the
RAND Corporation in Santa Monica. But, he found, Americans got just
half the tests and treatments they should be getting.
"Basically, it was a flip of coin, whether you got good medical care or
you didn't," Dr. Asch said. "It didn't matter where you lived. The
shortfalls were constant."
"That challenged us to ask why these medical care problems were so
pervasive," he said.
At least part of the answer, he and others say, is that doctors are
unaware of their shortfalls and are rewarded no matter how well they
do.
"Medical care is one of those very strange parts of the economy where
you get paid no matter what the quality of the service you provide,"
Dr. Asch said. "It is like you went to a car dealership and your
Mercedes is going to cost you the same as your Yugo."
Administrators at Medicare are well aware of the problem, Dr. Jencks
said.
"We've reached a conclusion," he said. "We have to change the system."
Dr. Jencks said he expected that in the future hospitals and doctors
would be paid according to whether they gave patients treatments that
worked. "It is very clear that we are moving toward
pay-for-performance," he said.
Change, though, will require fundamental alterations in how hospitals
and doctors' offices operate, health care researchers say. And it is
not so easy to change a medical system, as Hackensack University
Medical Center discovered.
"We tried to come up with a standardized order set," with all the
measures that Medicare was asking about, Dr. Gross said. "But the
doctors didn't want to use the sheet," insisting they would just
remember those items. Then they forgot.
The solution, Dr. Gross said, was to assign specially trained nurses to
see what care was provided and remind doctors when important steps were
omitted. The result was immediate improvement, Dr. Gross said, even in
items not on Medicare's list.
For example, doctors at Hackensack were keeping pneumonia patients in
the hospital, receiving intravenous antibiotics, for one to two weeks
when many could go home within days with antibiotic pills, avoiding the
discomfort from the intravenous lines and the ensuing risk of
infection. By putting a nurse on the case, patients were sent home
sooner. The hospital saved $500,000 a year by refilling its beds with
other patients. Medicare, which pays most of the bill for pneumonia
patients, reimburses for a diagnosis - pneumonia - and not for the
number of days a patient spends in the hospital, so keeping patients in
the hospital longer costs money.
Of course, the economics of medical care are rarely simple and the new
programs have so far steered clear of the most difficult category:
medical care that is useless or unnecessary, a category that costs the
nation hundreds of billions of dollars a year.
"That will be a bitter pill to swallow, and I'm not sure people will
swallow it," Dr. Califf said. "There's a lot of money being made on
things that don't work well."
Dr. Jencks agreed.
"I would say we are moving much more slowly on trying to prevent
overuse than in trying to fix underuse," he said. "If I tell a
physician he shouldn't do a surgery he wants to do, I personally would
anticipate a lot more resistance than if I told him he should give a
medicine he wasn't thinking of giving."
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