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When numbers don't tell the story

Hospital performance and patient outcomes may not be tracked thoroughly enough.

July 10, 2006|Shari Roan | Times Staff Writer

As healthcare costs skyrocket, consumers are urged to shop as carefully for medical care as they do for new homes or cars to obtain the best service and quality.

A new study suggests, however, that people need more reliable information than is available to make sound choices and to force more doctors and hospitals to provide high quality service in exchange for the prices they charge.

The article, in last week's Journal of the American Medical Assn., found that a hospital's publicly reported performance measures, which typically explain what "processes" are used to treat patients, may not reveal enough about the actual consequences for patients -- such as how likely they are to survive a medical crisis.

Specifically, the study found that death rates over the short term among patients who have had a heart attack cannot be reliably inferred from these "process" performance measures.

"We know there are some things that are really important to do for patients having heart attacks," says Dr. Harlan M. Krumholz, coauthor of the study and a professor of medicine at Yale University.

"The question we asked is: If [hospitals] are doing well on these things, are they doing well on survival rates?"

The answer: not necessarily.

The study did find that hospitals following recommended heart-attack treatment guidelines -- such as prescribing beta blockers and aspirin at the time of hospital admission and discharge, and the use of medications called ACE inhibitors -- had better survival rates.

The study also found a weaker correlation -- although still statistically significant -- between counseling for smoking cessation and better health outcomes.

However, these measures together accounted for only 6% of the difference among hospitals in short-term death rates for heart attack patients. The majority of outcome differences had to do with factors that were not being measured.

What this means, says Krumholz, is that hospital performance isn't being tracked thoroughly enough.

By law, hospitals are required to submit data on certain "core" performance categories, such as care after a heart attack.

The Centers for Medicare & Medicaid and the Joint Commission on Accreditation of Healthcare Organizations monitor and report the data. These measures are considered to be indicators of quality of care.

But the degree to which these performance measures convey meaningful information has remained unclear.

For example, although many hospitals now adhere to standard heart attack care protocols, such as providing aspirin and beta blockers, survival rates may vary among hospitals because of other factors that are typically not evaluated, Krumholz says.

These could include the time elapsed in responding to the emergency, the rate of medical errors and hospital staffing issues.

"It's possible for a hospital to cut corners in one area" in a way that affects overall quality of care, he says.

Thus, he adds, "I think it's important to include an overall summary, such as survival."

Based on their study, Krumholz and coauthors called for 30-day mortality rates to be included in hospital performance measures for heart attacks in the United States.

Such a measure is already in place in California, which posts 30-day death rates for several common medical conditions.

But the practice is not standard elsewhere.

Hospital performance measures are considered key to the future of high-quality health care, says Dr. Ashish K. Jha, an assistant professor of health policy and management at the Harvard School of Public Health, in an editorial accompanying the study.

"More information is needed on processes and outcomes across a large number of conditions for hospitals, physician practices, and other heath care settings and practitioners," he wrote.

Routine publication of performance measures of hospitals and individual doctors puts valuable information into consumers' hands, says Krumholz.

"It starts the conversation" about quality, he says. "People start talking. Doctors start talking. Payers start rewarding hospitals that provide this information.

"There are ways to put pressure on the system so they have to improve quality."

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