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Heart attack report wins praise

Thursday, April 02, 1998

By Anita Srikameswaran, Post-Gazette Staff Writer

A government report that evaluated heart attack treatment in Pennsylvania has itself been scrutinized and has received an excellent grade.

Researchers reviewed the methods the Pennsylvania Health Care Cost Containment Council used to compare hospitals' and physicians' 1993 results in dealing with heart attacks -- a scorecard called "Focus on Heart Attack" that was published in June 1996.

According to cardiologist James Jollis, of Duke Clinical Research Institute in Durham, N.C., the council produced one of the best reports in the country. By monitoring hospitalizations, procedures and complications, people can assess whether costs are being cut at the expense of patient well-being.

New York, Colorado, California and some regional coalitions have prepared or are preparing similar reports. Not all are intended for public use, however.

"A system like what Pennsylvania has in place is extremely important in the current era to ensure patients get good care," he said. "You can follow trends. If you see people are doing worse with short hospital stays, then you can go to longer stays. If you don't look, you won't pick that up."

The council tried to take into account differences in patient health before the heart attack, because some people are more ill than others, and examined statewide information using sophisticated computerized medical databases, leveling the playing field for comparison of doctors and hospitals.

But the accuracy of the results could be improved by collecting better data on patients and their care, Jollis and co-author Dr. Patrick Romano write in today's issue of the New England Journal of Medicine.

People who had heart attacks were identified through insurance bills -- documents that were meant to figure out payments, not confirm the diagnosis, Jollis explained. And some patients started off at one hospital and were transferred to another; even if they died at the second hospital, the death was attributed to the first.

Another problem, common to most studies of this nature, was an inability to be certain if a patient had a condition, such as shock or kidney failure, prior to the heart attack or because of it.

If a hospital says the patient had the condition before the heart attack occurred, the hospital may get credit for treating someone "sicker" when the problem was actually caused by poor treatment.

Such inaccuracies in data can lead to faulty conclusions.

"It would likely change the rankings of hospitals and physicians in the report," Jollis said. "That would make a huge difference to (those) that were identified as better or worse. We're not quite at the point yet where we're able to identify who's better or worse in a public report."

All of the concerns the researchers raised had been extensively discussed in the development of the report, said Marc Volavka, director of operations. The council and its technical advisers did the best they could to address those issues.

Efforts to "clean up the data" have been continuing, particularly to deal with distinguishing pre-existing conditions from complications, Volavka noted. The council hopes to release a report on coronary artery bypass grafts in May that includes updated data.

"We felt very pleased with the (New England Journal) article itself," he said. "The council is somewhat unique nationally, and certainly, public reporting on the hospital and physician level is truly unique."

Both Jollis and Volavka emphasized that the report was not meant to tell people where or to whom to go for heart attack care.

"We never painted this as a consumer guide," Volavka said. "If you even think you're having a heart attack, get care as quick and close as you can."

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