December 25, 2004
Program Coaxes Hospitals to See Treatments Under Their Noses
For now, the effort involves three common and deadly afflictions of theelderly - heart attacks, heart failure and pneumonia - and asks about lifesavingtreatments that everyone agrees should be given but that hospitals and doctorsoften 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 doctorswill 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 organizationsof hospitals, doctors, nurses, and health researchers, to push providersto use proven remedies for common ailments.
And it is a response to a sobering reality: lifesaving treatments oftenare forgotten while doctors and hospitals lavish patients with an abundanceof care, which can involve expensive procedures of questionable value. Theresults are high costs, unnecessary medicine and wasted opportunities tosave lives and improve health.
Simple things can fall through the cracks.
"In some ways, it's kind of scary," said Dr. Peter Gross, thechief of the department of internal medicine at Hackensack University MedicalCenter in New Jersey. "The doctor today is much too busy and has toomuch 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 discoverthey have been forgetting some of the very treatments that can make a differencebetween life and death, or sickness and health.
At Duke University's hospital, for example, when patients arrived shortof breath, feverish and suffering from pneumonia, their doctors monitoredtheir blood oxygen levels and put them on ventilators, if necessary, tohelp them breathe.
But they forgot something: patients who were elderly or had a chronicillness like emphysema or heart disease should have been given a pneumoniavaccine to protect them against future bouts with bacterial pneumonia, amajor killer. None were.
All bacterial pneumonia patients should also get antibiotics within fourhours of admission. But at Duke, fewer than half did.
The doctors learned about their lapses when the hospital sent its datato Medicare. And they were aghast. They had neglected - in most cases simplyforgotten - the very simple treatments that can make the biggest differencein how patients feel or how long they live.
"It's like the Elisabeth K¸bler-Ross stages of grief,"said Dr. Robert Califf, a professor of medicine at Duke. "First you'rein shock, then denial, and then you gradually come to terms with what needsto be done."
Now, Dr. Califf said, the hospital is scrambling to make sure such treatmentsare not neglected again.
Department of Veterans Affairs doctors had also been forgetting treatmentslike the pneumonia vaccine, said Dr. Jonathan Perlin, the agency's actingunder 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 thevaccine received it (the national average is 50 percent). The rude awakeningcame when the department showed individual teams of doctors and individualclinics and hospitals how often they were vaccinating and how their ratescompared with those of other medical teams. "It's pretty revealingto have the data," Dr. Perlin said. "Absent the data, you thinkyou 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 patientswith emphysema, the V.A. saved 6,000 lives," Dr. Perlin said.
The same strategy worked with beta blockers - drugs, costing penniesa day, that should be given to nearly all heart attack patients within 24hours 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 andsave more than $6,000 per patient in hospitalization over five years.
The Department of Veterans Affairs has gone from giving beta blockersto 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'sentire system, saving patients' lives across the board.
That happened when Duke researchers asked 315 hospitals for data on ninedrugs that everyone agrees should be provided to heart attack patients.
For example, the hospitals were asked how often their heart attack patientsgot 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 cholesterollevels? Nearly all should, with the exception of patients who have had abad reaction to a statin and those rare patients with very low cholesterollevels. Did they get a beta blocker?
Once hospitals learned their score, it was up to them what to do. Overthe next year, ones that improved in these measures saw their patient mortalityfrom all causes fall by 40 percent. Those whose compliance scores did notchange had no change in their mortality rate, and those whose performancefell had increases in their mortality rates.
"Those are the most remarkable data I have ever seen," saidDr. Eric Peterson, the Duke researcher who directed the study and has reportedon 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 scientificknowledge about what quality means," Dr. Califf said. And there wasa growing realization that quality care was not always being provided.
But when it comes to improving care, there is always the contentiousissue of deciding what is good medicine.
"Most of what we do has a modest effect, and that means, by thevery nature of the effects, that you can't tell whether what you are doingis effective unless you do a study," Dr. Califf said.
But that takes time, money, and often thousands or tens of thousandsof patients. In most cases, such studies have not been done.
Dr. Califf and others cited bed sores as an example. The nation spendsbillions of dollars a year on special bandages and beds and treatments."None of these is proven," Dr. Califf said. "But if you aremaking a ton of money being reimbursed by Medicare, the last thing you wantto do is put your treatment to a test."
So, at Medicare, administrators decided to focus on just a few treatmentsat first, for a few common diseases - pneumonia, heart attacks and heartfailure - where there was little controversy about whether those treatmentsworked and an abundance of data showing that doctors and hospitals oftendid not provide them.
"We made an initial decision, which was very political," saidDr. Stephen Jencks, Medicare's director of quality coordination."We were going after things where there was complete agreement thata service was not being provided."
They are only a start. "Almost everyone would agree they are a verynarrow slice of the health care pie."
So the agency asked the nation's hospitals to report how well they didin providing these treatments if they wanted this year's cost-of-livingincrease 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 awkwardif everyone else is doing better and they're not," Dr. Jencks said.
The next step, Dr. Stephen Jencks, Medicare's director of qualitycoordination, said, is "aligning payment with what you want peopleto do."
To that end, Medicare has a pilot program to pay hospitalsfor improving on a number of quality measures, including mortality ratesand readmission rates for hip or knee surgery. Hospitals in the top 10 percentfor a given condition, for example, will be paid an extra 2 percent. Theagency will pay less if performance deteriorates. The project involves 278hospitals affiliated with Premier, a nationwide organization of nonprofithospitals.
The new initiatives have one thing in common - they abandoned the traditionalassumption that if doctors know what works, they will provide it.
Doctors do know what works, said Dr. Steven M. Asch, a health care researcherat the V.A. Greater Los Angeles Health Care System and the RAND Corporationin Santa Monica. But, he found, Americans got just half the tests and treatmentsthey should be getting.
"Basically, it was a flip of coin, whether you got good medicalcare or you didn't," Dr. Asch said. "It didn't matter where youlived. The shortfalls were constant."
"That challenged us to ask why these medical care problems wereso pervasive," he said.
At least part of the answer, he and others say, is that doctors are unawareof their shortfalls and are rewarded no matter how well they do.
"Medical care is one of those very strange parts of the economywhere 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 Mercedesis going to cost you the same as your Yugo."
Administrators at Medicare are well aware of the problem, Dr. Jenckssaid.
"We've reached a conclusion," he said. "We have to changethe system."
Dr. Jencks said he expected that in the future hospitals and doctorswould 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 hospitalsand doctors' offices operate, health care researchers say. And it is notso easy to change a medical system, as Hackensack University Medical Centerdiscovered.
"We tried to come up with a standardized order set," with allthe measures that Medicare was asking about, Dr. Gross said. "But thedoctors didn't want to use the sheet," insisting they would just rememberthose items. Then they forgot.
The solution, Dr. Gross said, was to assign specially trained nursesto see what care was provided and remind doctors when important steps wereomitted. The result was immediate improvement, Dr. Gross said, even in itemsnot on Medicare's list.
For example, doctors at Hackensack were keeping pneumonia patients inthe hospital, receiving intravenous antibiotics, for one to two weeks whenmany could go home within days with antibiotic pills, avoiding the discomfortfrom the intravenous lines and the ensuing risk of infection. By puttinga nurse on the case, patients were sent home sooner. The hospital saved$500,000 a year by refilling its beds with other patients. Medicare, whichpays 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 newprograms have so far steered clear of the most difficult category: medicalcare that is useless or unnecessary, a category that costs the nation hundredsof billions of dollars a year.
"That will be a bitter pill to swallow, and I'm not sure peoplewill swallow it," Dr. Califf said. "There's a lot of money beingmade on things that don't work well."
Dr. Jencks agreed.
"I would say we are moving much more slowly on trying to preventoveruse than in trying to fix underuse," he said. "If I tell aphysician he shouldn't do a surgery he wants to do, I personally would anticipatea lot more resistance than if I told him he should give a medicine he wasn'tthinking of giving."