Study shows 10-year effort, major medical advances improved survival
TUESDAY, Aug. 18 (HealthDay News) -- A decade-long, government-led effort has reduced the death rate for patients hospitalized for heart attacks and improved the performance of hospitals that deal with these daily emergencies, a nationwide study finds.
Between 1995 and 2006, the in-hospital death rate for Medicare patients treated for heart attacks decreased, from 14.6 percent to 10.1 percent, while the 30-day death rate in such cases dropped from 18.9 percent to 16.1 percent, according to a report in the Aug. 19 issue of the Journal of the American Medical Association.
For the study, a team of cardiologists reviewed the outcomes of more than 2.7 million cases reported by more than 500 hospitals. Over the same period, the 30-day death rate for all other conditions barely changed, from 9 percent in 1995 to 8.6 percent in 2006, the report noted.
While the decade saw major advances in the drugs and techniques used to treat heart attacks, the key element in the overall improvement was the effort by what was then the Health Care Finance Administration and now is the Center for Medicare & Medicaid Services (CMS), said study author Dr. Harlan M. Krumholz, a professor of medicine at Yale University School of Medicine.
"What CMS did was critical," Krumholz said. While other organizations, such as the American Heart Association (AHA) and the American College of Cardiology, also emphasized good heart care in hospitals, "I don't think it would have happened without a shift by Medicare in saying, 'We have to look at the entire group of hospitals'," he said.
Until the early 1990s, "the whole idea of quality improvement was to find the bad apples," he said. "The pivotal point was Medicare saying, 'We're not going to focus only on the outliers'."
There were plenty of outliers -- hospitals whose heart attack treatment results lagged behind the outcomes of most others. In the 1990s, heart attack death rates of more than 24 percent were noted at 39 hospitals. In 2006, no U.S. hospital reported such a high rate, and the death rate in the worst 1 percent was 19.5 percent.
Overall, the difference between the results obtained at all hospitals narrowed considerably, from 4.4 percent to 2.9 percent.
Improvement was achieved without coercion, with CMS simply keeping hospitals informed of what could be done, said AHA President Dr. Clyde W. Yancy, director of the Baylor Heart and Vascular Institute in Dallas. This was helped by a legislative mandate requiring hospital reporting of data.
"One of the best strategies to influence behavior is to make a facility or individual physician aware of their own results," Yancy explained. "Medicare was making individual centers aware of their own information."
Other striking changes also occurred during the decade. The average hospital stay for a heart attack decreased by nearly 16 percent, from 7.9 days in 1995 to seven days in 2006. Many more survivors were sent to a skilled nursing facility or intermediate care center instead of straight home -- 9.3 percent in 1995-96 vs. 17.4 percent in 2006.
The focus on improvement also came at a unique time in the history of cardiology, when major advances in heart attack treatment became available, Yancy said.
"There has to be an alignment in the process of care development and the methods used to measure outcome," he said. "You need the best science and the best process of instilling the implementation of these developments."
Because similar medical advances are not being made across the board, the program that improved heart attack treatment results won't necessarily apply to all cardiac patients, Yancy said. Notably, no such improvement has been seen in people hospitalized with heart failure, the progressive loss of ability to pump blood that can be life-threatening, he said.
"In heart failure, we don't see nearly the same reduction," Yancy said. "We actually don't have much evidence about how to improve pivotal-point care in heart failure. The result in advanced heart failure has been negative."
Warning signs that hospital treatment for a possible heart attack is needed are described by the American Heart Association.
SOURCES: Harlan M. Krumholz, M.D., Harold Hines Jr. Professor of Medicine and Epidemiology and Public Health, Yale University School of Medicine, Newe Haven, Conn.; Clyde W. Yancy, M.D., FACC, FAHA, FACD, director, Baylor Heart and Vascular Institute of Baylor University Medical Center, Dallas; Aug. 19, 2009, Journal of the American Medical Association
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