JUST about everyone in medicine agrees that a patient who shows up in the emergency room with a heart attack should be given aspirin. That simple treatment has been proved to cut death rates by nearly a quarter.
But hundreds of patients at hospitals in New Jersey do not get that aspirin, or nine other crucial therapies for heart attack, heart failure and pneumonia, a review of recently published hospital data shows. Some hospitals are better than others, but none delivered all the treatments to eligible patients, in spite of their well-known benefit.
Last month, The New England Journal of Medicine reported that, although their performance had improved somewhat from 2002 to 2004, hospitals across the country were neglecting many lifesaving treatments. The journal also reported on another study that found that hospitals around Boston and Oklahoma City performed better than those in other regions, but that even in those places hundreds of patients did not get basic therapies.
A review of the data by The New York Times showed that, as a group, hospitals in New Jersey tended to perform better than those in New York, but not as well as hospitals in Connecticut or Massachusetts. Twenty-two of the state's 75 participating hospitals were in the top 10 percent of the nation in at least one of the conditions.
The hospital performance data are collected by the federal Department of Health and Human Services under a program called Hospital Compare and cover 10 treatments considered essential for most patients. They include admissions from January to June 2004. Detailed information is online at www.hospitalcompare.hhs.gov.
"We really should be close to 100 percent on all of these measures," said Dr. Ashish Jha, of the Harvard School of Public Health, an author of one of the national studies published last month. "There's not much controversy about whether giving antibiotics to someone who has pneumonia is good or not."
Besides aspirin for heart attack and antibiotics for pneumonia, the measures include beta blockers for heart attack, angiotensin-converting enzyme inhibitors for heart failure and heart attack, and vaccinations for pneumonia.
Heart attack is an acute episode, usually requiring an emergency room visit, caused by constriction of flow in a coronary artery. Heart failure is a chronic condition, essentially the wearing out of the heart muscle to the point it cannot pump enough blood.
Over all, New Jersey hospitals delivered appropriate treatment to heart attack victims 94 percent of the time, to heart failure patients 89 percent of the time and to pneumonia patients 79 percent of the time, better than New York hospitals as a group, and above the national average.
The numbers also represent a significant improvement since 1998, when an article in The Journal of the American Medical Association put New Jersey 41st in the nation in delivering these treatments to Medicare patients.
"On one of the indicators, making sure aspirin is administered for heart attack, we were doing that less than 50 percent of the time at one point," said Aline Holmes, director of the Quality Institute, an arm of the New Jersey Hospital Association. "It's shown to reduce mortality, and we just have to do better."
Last year, the state health department prodded hospitals into making improvements by producing its own report card, using these measures, and it appears to have helped: For heart attack care, New Jersey now ranks 21st.
"You need a focused, almost surgical approach to the areas of the institution that have opportunities for improvement," said Dr. Clifton Lacy, the president of Robert Wood Johnson University Hospital in New Brunswick and the former state health commissioner who championed the report cards. His hospital ranks in the top 12 percent of all hospitals in the country in all three measures.
At Hackensack University Medical Center, officials ripped up and rewrote their protocols of care to ensure that patients got the treatments.
"We ended up changing the way we do business," said Dr. Charles Riccobono, chairman of the performance improvement department at Hackensack.
For instance, pneumonia patients can show ambiguous symptoms that delay diagnosis, and thus delay delivery of antibiotics beyond a four-hour window in which they are proved to save more lives. Nurses and doctors were given a refresher course to increase their awareness of the potential for undiscovered pneumonia in patients. Antibiotic dispensing was moved from a central pharmacy to the emergency room to save minutes.
The result: Patients got the appropriate treatment 92 percent of the time, which put the hospital into the top 5 percent of hospitals nationwide.
"Doctors can be stubborn," Dr. Riccobono said. "In order to get a uniform process, and take the variability out, you get them together, let them go over this stuff and eventually, they make it their own. It's called physician buy-in."
