Hospitals Had Notice of Troubles
When a recent national study ranked Inland Empire hospitals the worst in the nation for treatment of heart attacks and pneumonia, some hospital officials blamed poor record-keeping. Several expressed bafflement and surprise.
But a review of previous studies by the state suggests that many of the hospitals in Riverside and San Bernardino counties had been on notice for years that their patients were dying significantly more often than expected from these conditions.
Eleven hospitals in the two counties had more patients die from pneumonia than expected from 1999 to 2001, according to a 2004 report by the California Office of Statewide Health Planning and Development. The data were adjusted to account for the severity of patients’ illnesses.
The two counties had no hospitals whose death rate was markedly better than expected.
Separately, a 2002 report from the same agency found that five hospitals in the region had higher-than-expected death rates for heart attack patients from 1996 to 1998. Only one hospital from the area did better than expected.
“The question would be, naturally, what did you do when you saw these results several years ago? Did you review your care of these patients?” said Dr. Patrick S. Romano, a professor of medicine and pediatrics at UC Davis. “It would be logical for a hospital to say, ‘We’re not looking so good on our pneumonia mortality.’ ... That’s the way it’s supposed to work.”
The most recent study, published last month in the New England Journal of Medicine, looked not at death rates but at whether hospitals followed accepted national standards in treatment of pneumonia, heart attacks and congestive heart failure. For example, it gauged whether hospitals gave patients appropriate medications on time.
It found that hospitals serving the Inland Empire overall ranked last among the largest 40 hospital markets for treating heart attacks and pneumonia. The hospitals ranked 34th out of 40 for care of congestive heart failure patients.
The national study, by a team of Boston researchers, was based on data the hospitals submitted to the federal government for the first half of 2004. The Inland Empire market included 21 hospitals, some in Riverside County, some in San Bernardino County. There are more than 30 hospitals in the two counties.
Information on individual hospitals is available online at www.hospitalcompare.hhs.gov.
The previous studies showed that some hospitals have had recurrent problems in certain treatment areas.
Riverside Community Hospital, for example, was among the hospitals rated worst for pneumonia deaths from 1999 to 2001. Its mortality rate was more than 20%, compared with the statewide average of 12%, the 2004 report showed.
Then, based on the data it submitted to the federal government last year, Riverside Community scored below average for giving pneumonia patients appropriate vaccines and ensuring they received antibiotics promptly when they arrived at the hospital.
Thom Walsh, the hospital’s vice president of quality and safety, said Riverside Community had improved its care of pneumonia patients dramatically since the 1999-2001 period.
“It’s relevant to look at the data from a historical perspective, but it in no way reflects what we’re doing today,” he said. “We have quality systems in place to internally monitor our pneumonia mortality. In looking at that over time, we’ve seen a downward trend.”
For the first quarter of 2005, the hospital’s mortality rate was 4.7%, when adjusted for the severity of its patients’ illnesses -- below the national average, Walsh said.
He also said the hospital was working to improve its compliance with national standards on administering vaccinations and antibiotics.
“We’re seeing improvement over time,” he said.
Riverside County Regional Medical Center likewise was ranked among the worst hospitals in the state for its pneumonia death rate from 1999 to 2001. It also fared poorly, compared with the national average, in complying with treatment standards last year, based on the website data.
Douglas Bagley, the public hospital’s chief executive, said his staff was looking at ways to improve. At the same time, he struggled to explain why hospitals in his region fared so poorly in the latest study.
“I don’t have any explanation for that,” he said. “I don’t really have any ideas.”
Moreno Valley Medical Center had higher than expected death rates from heart attacks from 1996 to 1998, and the federal website shows that it did not meet some heart attack treatment standards last year.
The hospital, for instance, gave aspirin to only 78% of heart attack patients within 24 hours of their arrival, below the national average of 91%. It gave beta blockers to arriving heart attack patients only 69% of the time, below the national average of 83%.
On other measures of heart attack treatment, the hospital scored at or above the national average.
Some hospitals rated well overall in the most recent study after a poor showing several years before.
Arrowhead Regional Medical Center had one of the highest mortality rates in the state for heart attack patients from 1996 to 1998, according to the 2002 state report. Its data submitted to the federal government last year show that the hospital is now exceeding national averages for following standards of care.
Dr. Dev GnanaDev, Arrowhead’s medical director, attributed the hospital’s recent success to protocols that spell out exactly how doctors and nurses should treat patients with heart attacks. The same types of rules are being put in place for pneumonia, where the hospital’s scores are not as good.
“It’s getting there,” he said. “I think everyone is trying pretty hard.”
GnanaDev and other experts said hospitals were motivated to improve, in part, because their data were being publicly reported.
“Finally, the lightbulb has gone off and people are really looking at this data in ways that are going to make real change, in ways that are going to save lives,” said Dr. Robert Wachter, a patient safety expert at UC San Francisco Medical Center.
A top official at the California Department of Health Services said the new data on whether hospitals adhere to national treatment standards ultimately would be helpful to her agency as it inspected hospitals. For now, regulators review patient charts, walk around the hospital, interview staff members and talk to patients to prepare their findings.
“We really feel as though these types of indicators could give us additional information to focus our surveys,” said Brenda Klutz, deputy director of licensing and certification at the state Department of Health Services.
“If a hospital scores lower than the nation or the region, a good question would be, what are you doing to correct this? What systems changes are you putting in place to improve patient outcomes?”
