Medicare’s ‘Gold Standard’ Being Devalued
If your 75-year-old mother enters the hospital for, say, hip surgery, the doctor who takes her medical history should check to see if she had a flu shot this year.
If Uncle Joe, a two-pack-a-day smoker at age 80, undergoes heart bypass surgery, he shouldn’t leave the hospital without first receiving counseling to help him quit smoking.
Seems like common sense, but lots of physicians and their patients don’t always take advantage of the obvious when it comes to either treatment or preventive care. That is one of the most compelling--and disturbing--messages from the first inside look at some basic measures of hospital treatment and preventive care provided to millions of people enrolled in Medicare.
A new study by federal researchers has some blunt criticisms. “Quality of care is and has been far more uneven than previously recognized,” the researchers wrote in an article published Wednesday in the Journal of the American Medical Assn.
The report found that quality varied significantly among states and regions. And the causes are a mystery, the report acknowledged: “We do not yet understand the reasons for these differences. . . .” It is all the more puzzling because Medicare covers virtually all Americans older than 65 and the disabled of all ages. The program offers a standard package of benefits, whether a person lives in Los Angeles or Miami. Yet there is considerable variability in the treatments provided by doctors and hospitals across the country.
Studies by researchers over the years have shown major variations in practice patterns in U.S. medicine. In some regions, heart patients are more likely to undergo bypass surgeries or women are more likely to undergo Caesarean sections during childbirth. In California, patients typically have shorter hospital stays than residents of most other states.
By contrast, the treatments studied by the federal researchers are relatively basic procedures and treatments on which there is broad agreement within the medical community about their scientific validity and efficacy.
For example, if heart attack victims routinely received an aspirin after reaching the hospital and a beta blocker to prevent another heart attack, 4,000 lives would be saved each year, according to Dr. David Thomas, a family physician from Iowa and president of the American Health Quality Assn, the industry representing contractors hired by Medicare to improve quality of care.
If everyone with an irregular heartbeat was given proper medication at the hospital, another 1,500 lives would be saved, Thomas told the news conference where the Medicare report was issued. Yet, while everyone in the medical field knows this, some hospitals and doctors are better than others at actually delivering this vital care.
Public-opinion polls show that many Americans have a deep distrust of health insurers and HMOs, while generally giving their own physicians high marks. But those trusted physicians may not always be following the best scientific advice in keeping their patients healthy.
The federal Medicare program is now spending lots of money, time and energy to change behavior. It wants to go from a passive payer of bills--spending more than $250 billion a year--to an agency that puts a special emphasis on the quality of care, said Dr. Jeffrey Kang, director of the office of clinical standards and quality for the Health Care Financing Administration, which runs Medicare.
Medicare wants hospitals and doctors to do a better job of living up to the so-called gold standard, the scientifically validated measures that can help patients survive illnesses or avoid getting sick in the first place.
The report offered a unique snapshot of the care Medicare beneficiaries receive, based on a scientific sampling of patient records. The lesson for consumers is clear: Take an active role in your own health care, asking questions and making sure you get the services that are considered part of optimal care. If patients are too ill or distracted, spouses, family members or friends should actively question doctors.
The Medicare study uses 24 separate measures for treatment of heart attacks, heart failure, stroke and pneumonia, and preventive care for breast cancer, diabetes and the flu.
For example, someone admitted to a hospital with a heart attack should get an aspirin within 24 hours of arriving to help keep the arteries open. The patient also should be given a beta blocker, a medication that slows the work of the damaged heart and helps it recover. Thrombolytic therapy, which helps dissolve blood clots, should be administered as quickly as possible, the study said.
When they are discharged, the heart attack patients should get aspirins and a prescription for beta blockers.
Warning to Doctors
People who come to the hospital suffering from a stroke have dangerously high blood pressure. The Medicare survey provides a warning: Doctors should be alert to problems that could arise when they try to bring down a patient’s blood pressure too rapidly. They should avoid the medication Nifedipine as a pill slipped under the tongue, because it would be quickly absorbed into the blood stream, posing a risk of lowering blood pressure too fast, reducing circulation and increasing the damage to the brain tissue of the stroke victim.
Patients with atrial fibrillation, an irregular heartbeat, should be given a blood thinner called warfarin.
People with congestive failure typically go to the hospital suffering from shortness of breath or swelling in the legs. Often, they are so weak they can barely walk. The standard treatment for the usual patient, someone with weakness detected in the left ventricle of the heart, is an ACE inhibitor, a medication which enhances the functioning of the heart muscle.
When someone is hospitalized with pneumonia, the recommendations call for a blood culture and the administration of an antibiotic within eight hours of arrival at the hospital.
Even the gold standard rules have exceptions, of course.
“You do these things unless there are contraindications--some reason why giving the medicine would have a bigger risk than a benefit for the patient,” said Dr. Ronald Bangasser, a family practice physician in Redlands.
Someone already taking a blood thinner medication shouldn’t take the aspirin because it could be dangerous, leading to possible internal bleeding. A patient with asthma or diabetes or with low blood pressure could be endangered by taking a beta blocker. In the realm of preventive care, however, there are no contraindications. Some measures should be universal, yet there are lots of people who aren’t getting what they deserve. People 65 and older should get a flu immunization every year, and a pneumonia vaccination at least once. Every woman older than 65 should have a mammogram every two years. Diabetics should have a blood test every year focused on Hemoglobin A1c, a measure of the blood sugar level. Every two years, diabetics should have a lipid profile, to check their cholesterol and an eye examination.
But in California, only 65% of diabetics in the sample surveyed had been given the Hemoglobin A1c test, contrasted with more than 80% in Minnesota, North Dakota, Vermont and Wisconsin.
The goal, unattainable as it may seem, is to approach 100%, with everyone making full use of the gold standard treatments and preventive tests, said Kang.
“This is a huge challenge for us as a research agency,” said Dr. John Eisenberg, director of the federal Agency for Healthcare Research and Quality. “We need to find out why differences exist among states and among individuals in the states,” he said at a news conference last week.
The Medicare report was just the starting point. Within a couple of years, Eisenberg’s office will produce a national quality report that will look at how many patients younger than 65 are getting a “gold standard” treatment from doctors and hospitals.
