A report in last week's Journal of the American Medical Association suggests that the quality of U.S. health care has improved over the past few years in certain measurable ways.
The study compared the rates at which a sampling of Medicare patients received specific treatments widely considered to be "best medical practices" in 2000-01 in contrast to 1998-99. The results show an average increase in use of best practices of about 12 percent nationwide, with improvements in 20 of 22 quality measures. (Gains were also seen in two other categories that were measured in minutes rather than percentages.) Best practices are typically in use about 75 percent of the time.
The report raised the question of what those measures of quality care are, how often they are applied in our area and whether patients can access hospitals' and other providers' comparative performance data.
Below we list the 24 quality practices cited in the report, along with their rates of application in Medicare patients for the 2000-01 period for the District, Maryland and Virginia. Data were gathered by jurisdiction, so information on particular hospitals or providers is not available. (See "Hospitals' 'Best Practices' Data Coming Online," below, for a report on available best practices and outcome data that consumers can use.)
INPATIENT TREATMENTS FOR ACUTE MYOCARDIAL INFARCTION (HEART ATTACK)
Regarding the practice of prescribing a beta blocker drug at discharge, Maryland hospitals (77 percent) trailed Virginia (88 percent) and D.C. (85 percent). More surprising were the percentages of smokers receiving smoking cessation counseling during hospitalization: 53 percent in Virginia, 39 percent in D.C. but just 27 percent in Maryland.
The data suggest that Maryland facilities handle heart attack patients faster, delivering thrombolytic therapy (drugs that dissolve blood clots) in about 30 minutes and angioplasty (a procedure that physically opens blocked arteries) in an average of 83 minutes. Virginia manages thrombolytic therapy in 51 minutes and angioplasty in an average of 141. Thrombolytic therapy numbers were not available for the District, but its average time to angioplasty is 177 minutes -- nearly three hours.
The treatments that were measured in this category:
* Aspirin given within 24 hours of admission: D.C. 87; Md. 85; Va. 89.
* Aspirin prescribed at discharge: D.C. 91; Md. 87; Va. 90.
* Beta blocker drug given within 24 hours of admission: D.C. 69; Md. 71; Va. 67.
* Beta blocker prescribed at discharge: D.C. 85; Md. 77; Va. 88.
* ACE inhibitor drug prescribed at discharge if left ventricular ejection (a measure of the heart's ability to pump blood to the body) is less than 40 percent: D.C. 78; Md. 79; Va. 78.
* Smoking cessation counseling: D.C. 39; Md. 27; Va. 53.
* Time to thrombolytic therapy, in minutes: D.C. n/a; Md. 30; Va. 51.
* Time to angioplasty, in minutes. D.C. 177; Md. 83; Va. 141.
INPATIENT TREATMENTS FOR CONGESTIVE HEART FAILURE
In this area of care, Maryland providers get ACE inhibitor drugs to the patients for whom they are indicated just 61 percent of the time, compared to 72 and 73 percent for D.C. and Virginia.
* Evaluation of ejection fraction: D.C. 75; Md. 75; Va. 80.
* ACE inhibitor prescribed for patients with ejection fractions less than 40 percent: D.C. 72; Md. 61; Va. 73.
INPATIENT STROKE TREATMENT
Intra-regional differences aren't very significant in this category of practice. But it's worth noting that area jurisdictions average just 55 percent in prescribing warfarin, a blood thinner drug for irregular heartbeat, but 98 or 99 percent in avoiding sublingual nifedipine (a drug that's been shown to lower blood pressure dangerously in some stroke patients) in the case of acute stroke.
* Warfarin (blood-thinning medication) prescribed for those with atrial fibrillation (irregular heartbeat): D.C. 55; Md. 55; Va. 56.
* Antithrombolytic (blood-thinnning) prescription at discharge for those with acute stroke or transient ischemic attack: D.C. 82; Md. 84; Va. 88.
* Avoidance of sublingual nifedipine for patients with acute stroke: D.C. 99; Md. 99; Va. 98.
INPATIENT PNEUMONIA TREATMENTS
Across all three jurisdictions, patients hospitalized with pneumonia are checked to see if they have received influenza or pneumococcal vaccine -- and given them if they haven't -- about a quarter of the time. Overall, immunizing Medicare patients with those two vaccines occurs nearly twice that often.
* Antibiotic prescribed within eight hours of arrival at hospital: D.C. 82; Md. 83; Va. 87.
* Antibiotic consistent with current recommendations: D.C. 82; Md. 88; Va. 88.
* Blood culture done before antibiotic given: D.C. 65; Md. 7; Va. 84.
* Screened for and given flu vaccine: D.C. 27; Md. 31; Va. 21.
* Screened for and given pneumococcal vaccine: D.C. 25; Md. 28; Va. 26.
IMMUNIZATION AGAINST PNEUMONIA
The District falls at least 10 percentage points behind Maryland and Virginia on these measures.
* Yearly flu vaccine: D.C. 61; Md. 72; Va. 74.
* Pneumococcal shot at least once: D.C. 48; Md. 67; Va. 63.
BREAST CANCER SCREENING
Again, the District lags the other jurisdictions by about 10 percentage points in providing mammograms to Medicare patients.
* Mammogram at least every two years: D.C. 52; Md. 61; Va. 60.
The District trails here, with 65 percent of patients getting the hemoglobin A1c test yearly (Virginia hits 80 percent, Maryland 77) and performing a lipid profile (a check of cholesterol and other blood fats) 68 percent of the time, compared to Maryland's 79 percent.
* Hemoglobin A1c test yearly: D.C. 65; Md. 77; Va. 80.
* Eye exam at least every two years: D.C. 69; Md. 69; Va. 70.
* Lipid profile at least every two years: D.C. 68; Md. 79; Va. 74.