More than 4,000 U.S. hospitals report the actions they take to treat a patient who has suffered a heart attack so that the Centers for Medicare and Medicaid Services (CMS) can evaluate the hospital's track record against 5 core quality measures. For heart attacks, these measures include giving aspirin and beta-blockers at admission and discharge and providing angiotensin-converting enzyme inhibitors or angiotensin receptor blockers at discharge to patients with low left ventricular systolic function. A new study finds that increasingly, patients have other medical conditions that may lead to doctors excluding patients from taking these drugs because of concerns that these patients may experience complications. Because a large number of older patients are potentially being discretionarily excluded from evaluation against the quality measures, publicly reported hospital quality scores may not be entirely accurate.
Researchers used 1994-1995, 1998-1999, and 2000-2001 data on admission for heart attacks from three CMS quality improvement projects. They found that patients with conditions that could lead to discretionary exclusions increased for four of the five measures from 1994 to 2001. In fact, patients with potential discretionary exclusions for aspirin at admission went from 15.8 to 16.9 percent, beta-blockers at admission jumped from 14.3 to 18.3 percent, aspirin at discharge rose from 10.3 to 12.3 percent, and angiotensin-converting enzyme inhibitors at discharge went from 2.8 to 3.9 percent.
The authors suggest that these findings bring to light a quandary many doctors face when treating older patients who have suffered heart attacks: Do the five quality measures provide optimum care for older patients, or is excluding them from the five measures the best course of treatment? Because older and sicker patients are mostly excluded from clinical trials, contraindications for treatment for these patients are unclear, so doctors are forced to rely on their discretion. The authors recommend researchers provide better evidence to help doctors provide the best care for older patients suffering from multiple ailments.
Further, because a large number of patients are being excluded from the five core measures, true care quality cannot be assessed, especially for older, sicker patients. Discretionary exclusions also complicate public reporting, because the public does not have access to quality data representing all patients seen at the hospital, just those who were included as ideal candidates for the quality measures. The authors recommend that public reporting systems provide more detailed information on the characteristics of included patients to give the public a clearer picture of what is actually being reported. This study was funded in part by the Agency for Healthcare Research and Quality (HS18283).
See "Who is missing from the measures? Trends in the proportion and treatment of patients potentially excluded from publicly reported quality measures," by Susannah M. Bernheim, M.D., M.H.S., Yongfei Wang, M.S., Elizabeth H. Bradley, Ph.D., and others in the November 2010 American Heart Journal 160(5), pp. 943-950.