Avoiding Heartbreak
Problem: Deaths in heart attack patients after they are admitted Proposal: Provide aspirin and a beta blocker early and at discharge; other measures Possible lives saved: 10,000
When a likely heart attack patient shows up at a good-sized hospital, the medical staff swings into action as if the curtain has risen on a carefully choreographed dance. That's not so far from the truth. They've seen lots of heart attacks, and each doctor, nurse, and technician plays a practiced role--taking a history, wiring up the patient to a 12-lead electrocardiograph that tracks heart rhythms and other activity, drawing blood for tests to help confirm a heart attack, starting an IV. Clinical guidelines map out each one of these steps in detail.
So it may seem like needless sermonizing for the 100K initiative to call for seven basic elements of heart attack care whose value no one seriously disputes: aspirin and a beta blocker on arrival, followed by prescriptions for both, plus either an ACE inhibitor or ARB medication (both are blood-pressure drugs) upon discharge; a clot buster within 30 minutes of arrival or a procedure to open blocked coronary arteries within two hours. Oh, yes, and counseling for smokers. These elements are, in fact, identical to those for which hospitals report their compliance to CMS for posting on the Hospital Compare website.
Prevention. Such measures are accepted not just because some of them help people survive a heart attack. Someone who has had a heart attack is vulnerable to another one in the days or weeks that follow, and studies indicate that the recommended medications can keep that from happening, too. Beta blockers, for example, may cut the risk of death by 13 percent the week after a heart attack and by 23 percent in the months after leaving the hospital.
Considering the well-documented benefits of these guidelines, one would assume all hospitals would obey them. But many don't. A large Rand study published in 2003, based on a review of thousands of medical records of individuals around the country, found that within two hours of entering the hospital, only 61 percent of heart attack patients got aspirin; just 42 percent were given a beta blocker.
A team from Hackensack's emergency department, cardiac service, and other parts of the hospital succeeded in boosting its performance dramatically when they started to follow the guidelines rigorously. In the first quarter of 2003, heart attack patients were receiving all seven services about 73 percent of the time. By the fourth quarter of the year, compliance had risen to 94 percent (it has stayed high through the most recent figures), and the hospital's death rate for heart attack patients had fallen from 7 percent to 5 percent. McLeod made a similar commitment, and its numbers, too, have improved significantly.
A trip to the Hospital Compare site is a revelation. The posted data suggest that at one prominent U.S. heart center, 16 of 174 heart attack patients didn't get a beta blocker on arrival, and 20 of 140 patients didn't get an ACE inhibitor. At another hospital with considerable expertise but a far lower public profile, virtually every patient was appropriately treated.
This story appears in the July 18, 2005 print edition of U.S. News & World Report.
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