Two papers appearing in JAMA this week send very different messages, although whether these differences are real or apparent is unclear. The first study provides evidence suggesting that improvements in MI treatment are resulting in significant improvement in outcome, the second paper suggests that changes in HF treatment are having little effect on outcomes.
In the first study, the 30-day-risk-standardized mortality rates (RSMRs) for MI declined from 18.8% in 1995 to 15.8% in 2006. The large new observational study also found a significant decrease in between-hospital variability of treatment.
“Although the cause of the reduction cannot be determined with certainty, this finding may reflect the success of the many individuals and organizations dedicated to improving care during this period,” conclude the authors, led by Harlan Krumholz. The authors used Medicare data from 3.2 million hospital discharges in 2.75 millions patients.
The second paper, a comment by Gregg Fonarow and Eric Peterson, reports that 30-day and 1-year mortality following heart failure admission remained flat in the period from 2002 to 2007, despite evidence showing improvement in a variety of performance measures, including measurement of LV function, use of ACE inhibitors or ARBs for LV systolic dysfunction, and provision of smoking cessation advice. But, the authors note, “it is critical to close the loop and verify that changes in care processes were actually associated with improved patient outcomes.”
In sharp contrast to the MI study, Fonarow and Peterson report that available HF data “suggest that 30-day and 1-year mortality (unadjusted or adjusted) following heart failure admission was relatively constant over this 6-year period, as were heart failure rehospitalizations (unadjusted or adjusted) and heart failure costs among the Medicare population.”
They write that “the most likely explanation is that these paradoxical findings are real. Of the 4 CMS-mandated heart failure performance measures, only 1 is supported by direct clinical trial evidence.” They conclude by calling for “fundamental change” in performance assessement, “from a purely competitive model of public dishonor and financial risk to collaborative learning systems that give caregivers the data feedback and resources necessary to make real changes in their patients’ quality of care and outcomes. Given the high and unabated postdischarge event rates for heart failure, the quality-assessment process needs to be transformed from one that provides only illusory gains to one that ensures true quality and outcome improvement.”
One expert observer who did not wish to be identified pointed out to CardioBrief that the HF data cited by Fonarow and Peterson is subject to misinterpretation. He noted that assessment of ejection fraction and treatment with ACE inhibitors or ARBs to treat LV dysfunction would not be expected to help HF patients with preserved systolic function, who represent a majority of patients. Furthermore, for heart failure, in contrast to MI, 30 day outcomes are too short a time to detect benefit, and even one year may be too short a time.
Here is the JAMA press release on the MI study:
Death Rate Decreases Following Hospitalization for Heart Attack
CHICAGO – From 1995 to 2006, hospital 30-day death rates decreased significantly for Medicare patients hospitalized for a heart attack, as did the variation in the rate between hospitals, according to a study in the August 19 issue of JAMA.
“Over the last 2 decades, health care professional, consumer, and payer organizations have sought to improve outcomes for patients hospitalized with acute myocardial infarction [AMI; heart attack],” the authors write. However, little has been known about whether hospitals have been achieving better short-term mortality rates for AMI or if there has been a reduction in between-hospital variation in short-term mortality rates, according to background information in the article.
Harlan M. Krumholz, M.D., S.M., of Yale University School of Medicine, New Haven, Conn., and colleagues examined 30-day risk-standardized mortality rates (RSMRs) for acute care hospitals in the United States in the period between 1995 and 2006 for Medicare patients, 65 years or older (average age, 78 years) who were hospitalized with an AMI. The study included data on 3,195,672 discharges in 2,755,370 patients.
The researchers found that the all-cause and in-hospital death rates decreased over the study period. “The 30-day mortality rate decreased from 18.9 percent in 1995 to 16.1 percent in 2006, and in-hospital mortality decreased from 14.6 percent to 10.1 percent. In contrast, the 30-day mortality rate for all other conditions was 9.0 percent in 1995 and 8.6 percent in 2006.” The RSMR, which takes into account the differences in the types of patients across hospitals and is currently being used by the Centers for Medicare and Medicaid Services (CMS) to profile hospital performance, decreased from 18.8 percent in 1995 to 15.8 percent in 2006, and a reduction in between-hospital differences in mortality rates was also observed.
“Between 1995 and 2006, the RSMR for patients admitted with AMI showed a marked and significant decrease, as did between-hospital variation. Although the cause of the reduction cannot be determined with certainty, this finding may reflect the success of the many individuals and organizations dedicated to improving care during this period,” the authors conclude.
(JAMA. 2009;302[7]:767-773.)
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