Quick, What Do You Do for A Heart Attack?

[Guest]

Westchester

Quick, What Do You Do for A Heart Attack?

By FORD FESSENDEN

Published: July 31, 2005

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 proven to cut death rates by nearly a quarter.

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New York Region

But hundreds of patients at hospitals in Westchester don't 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 benefits.

Earlier this month, The New England Journal of Medicine reported that, although performance had improved somewhat since 2002, hospitals across the nation were neglecting many lifesaving treatments. The Journal also reported on a study that found that hospitals around Boston and Oklahoma Cityperformed better than other large regions, but even in those places hundreds of patients did not get basic therapies.

A review of the data by The New York Times showed that Westchester was about average compared with the rest of the country, and similar to Manhattan. Only one hospital, Phelps Memorial Hospital Center in Sleepy Hollow, ranked in the top 10 percent nationally on five measures for treating heart attack, and no hospital ranked in the top 10 percent on the measures for treating heart failure and pneumonia. Five Manhattan hospitals ranked that high in treatment of at least one of the three conditions.

The hospital performance data is collected by the federal Department of Health and Human Services, and covers 10 treatments considered essential for most patients with one of the three conditions. They include admissions from January 2004 to June 2004.

"We really should be close to 100 percent on all of these measures," said Dr. Ashish Jha, a Boston physician and author of one of the studies. "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.

Some Westchester hospitals performed well on some measures, and not as well on others. Westchester Medical Center in Valhalla, for instance, gave all of its 67 heart attack patients aspirin at arrival, but administered ACE inhibitors to only 83 percent of 119 patients who should have received them.

Over all, some county hospitals were better than others. At Phelps, heart attack patients received all five treatments they should have received 99 percent of the time, while at St. Joseph's Medical Center in Yonkers, they received them only 72 percent of the time. St. Joseph's was also among the lowest in heart failure and pneumonia treatments. Officials there say they have taken action to improve their numbers.

"It's been a good process for us to go through to learn where we have to tighten procedures," said Lorraine Danaher Horgan, a vice president at St. Joseph's.

Hospitals have been privy to this or similar data for several years, and one of the articles in the New England Journal this month reported that performance on most measures had improved after hospitals realized how badly they were doing.

"Nobody wants to be the bottom guy," said Dr. Lawrence L. Faltz, the medical director at Phelps.

Sound Shore Medical Center in New Rochelle had below-average scores for all three conditions. "It takes a while for the docs to pay attention to this stuff," said Dr. Jeffrey Stier, the center's medical director. "The doctors say they're doing a good job, but when you break the numbers down to individual physicians, it's not always easy to see that."

Local and state hospital associations have endorsed the ratings, even though they may shine an unflattering light. (Detailed information on each hospital is available at www.hospitalcompare.hhs.gov.) Westchester hospitals have been on a campaign to emphasize quality in an effort to ensure that local patients don't go elsewhere for care, said Neil Abitabilo, the president of the Northern Metropolitan Hospital Association, to which most of the Westchester hospitals belong.

"We've got to make it clear to our communities that there's a level of excellence practiced here," he said, "so that people feel when they need hospital care, this is the place to get it."

For the county as a whole, heart attack patients were given treatments they should have received about 92 percent of the time, which is comparable to the figure in Manhattan. For heart failure, the figure was 77 percent, and for pneumonia 74 percent, which compare favorably with the 78 percent and 71 percent figures for Manhattan hospitals as a whole.

Dr. Jha said the measures did not gauge the ability or commitment of doctors as much as the competence of hospitals. "It's not that doctors don't know, or that doctors don't care," he said. "But hospitals are chaotic places."

Dr. Faltz said: "Hospitals are complex. There's a vast amount of information and a large number of people who have to take a bite out of that information, and the care processes have to be coordinated." Hospitals that build computer systems that remind and record information about treatments, and drill staff on guidelines, will deliver better care, he said.

The measures cover a narrow band of the range of care the hospitals deliver, but they involve common ailments, and are widely acknowledged to be necessary and crucial.

"These are the bread and butter of medicine," Dr. Jha said. "We know a tremendous amount about how to take care of these people. We know that if you walk in with a heart attack and I give you an aspirin, your chances of surviving have improved dramatically."

Dr. Jha's study showed that a hospital that did well treating one of the conditions didn't necessarily do well treating another, so a hospital's overall quality would be better judged by a wider range of measures.

But, he said, patients should use the ratings to make health care decisions.

"They can say, 'I am not going to hospital X and instead go to hospital Y,' " he said. If circumstances make it hard to go to another hospital, he said, "they can ask their doctors and nurses and administrators, 'Why are we not doing better?' "

Kudos to Phelps!

There is a graphic too, I'll scan and post it at some point.

Edited August 1, 2005 by JaredHG

[Guest paramedico987]

It's an interesting article really... but if you break it down we're talking about maybee 5 patients in each category not recieving all 5 treatments, to bring a reasonably good hospital (most in westchester are) down a few pegs.

My personal belief is that, while the "5 critical treatments" to which they are reffering to are important (for MI let's say), there's no need to administer anigiotensin converting enzyme inhibitors if simple nitrates do the trick on their own with ASA, heparin, and beta-blockers.

The treatments need to be tailored to the individual patient. There's no place for cookbook medicine here.

[JohnnyOV 2]

Did they check to see if the patient had taken asprin before they got to the hospital, or if they were given asprin by the EMT/Medic enroute to the hospital?

[Guest mediconpatrol]

Did they check to see if the patient had taken asprin before they got to the hospital, or if they were given asprin by the EMT/Medic enroute to the hospital?

<{POST_SNAPBACK}>

As a nurse who does some of the data entry on certain studies..Most of them do not include the prehospital treatment, therefore, the studies would not truly show the actual complete treatment of the patient

[Skooter92 7]

Giving an ACE inhibitor in the presence of MI isn't necessarily done for immediate relief of hypertension; nitrates and b-blockers do that. ACE inhibitors play a medium-to-long term role in management and also have other beneficial effects. Starting these patients on ACE inhibitors really is a good step in managing not only the acute condition, but pre-disposing conditions as well, and it's a pretty good indicator of comprehensive care being performed.