Program Coaxes Hospitals to See Treatments Under Their Noses

By GINA KOLATA

Published: December 25, 2004

The federal government is now telling patients whether their local hospitals are doing what they should.

For now, the effort involves three common and deadly afflictions of the elderly - heart attacks, heart failure and pneumonia - and asks about lifesaving treatments that everyone agrees should be given but that hospitals and doctors often 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 doctors will 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 organizations of hospitals, doctors, nurses, and health researchers, to push providers to use proven remedies for common ailments.

And it is a response to a sobering reality: lifesaving treatments often are forgotten while doctors and hospitals lavish patients with an abundance of care, which can involve expensive procedures of questionable value. The results are high costs, unnecessary medicine and wasted opportunities to save lives and improve health.

Simple things can fall through the cracks.

"In some ways, it's kind of scary," said Dr. Peter Gross, the chief of the department of internal medicine at Hackensack University Medical Center in New Jersey. "The doctor today is much too busy and has too much 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 discover they have been forgetting some of the very treatments that can make a difference between life and death, or sickness and health.

At Duke University's hospital, for example, when patients arrived short of breath, feverish and suffering from pneumonia, their doctors monitored their blood oxygen levels and put them on ventilators, if necessary, to help them breathe.

But they forgot something: patients who were elderly or had a chronic illness like emphysema or heart disease should have been given a pneumonia vaccine to protect them against future bouts with bacterial pneumonia, a major killer. None were.

All bacterial pneumonia patients should also get antibiotics within four hours of admission. But at Duke, fewer than half did.

The doctors learned about their lapses when the hospital sent its data to Medicare. And they were aghast. They had neglected - in most cases simply forgotten - the very simple treatments that can make the biggest difference in how patients feel or how long they live.

"It's like the Elisabeth Kübler-Ross stages of grief," said Dr. Robert Califf, a professor of medicine at Duke. "First you're in shock, then denial, and then you gradually come to terms with what needs to be done."

Now, Dr. Califf said, the hospital is scrambling to make sure such treatments are not neglected again.

Department of Veterans Affairs doctors had also been forgetting treatments like the pneumonia vaccine, said Dr. Jonathan Perlin, the agency's acting under 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 the vaccine received it (the national average is 50 percent). The rude awakening came when the department showed individual teams of doctors and individual clinics and hospitals how often they were vaccinating and how their rates compared with those of other medical teams. "It's pretty revealing to have the data," Dr. Perlin said. "Absent the data, you think you 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 patients with emphysema, the V.A. saved 6,000 lives," Dr. Perlin said.

The same strategy worked with beta blockers - drugs, costing pennies a day, that should be given to nearly all heart attack patients within 24 hours 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 and save more than $6,000 per patient in hospitalization over five years.

The Department of Veterans Affairs has gone from giving beta blockers to 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's entire system, saving patients' lives across the board.

That happened when Duke researchers asked 315 hospitals for data on nine drugs that everyone agrees should be provided to heart attack patients.