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Medical Care for Medicare Patients Needs Improvement, Says HCFA

Cheryl A. Thompson

Collaboration holds the best hope for improving the medical care that Medicare beneficiaries receive, an official of the Health Care Financing Administration (HCFA) told representatives from hospital, medical, and quality-improvement organizations on Tuesday.

"Partnerships are vital to succeeding in improvement," said Stephen F. Jencks, director of HCFA’s quality improvement group and lead author of an Oct. 4 Journal of the American Medical Association article (PDF) on Medicare quality of care. "There is a great deal of good care being provided, but there is a significant opportunity for improvement."

What’s good and bad in medical care for the elderly

The article reported the rates at which fee-for-service Medicare beneficiaries received appropriate care for the prevention or treatment of acute myocardial infarction, breast cancer, diabetes mellitus, heart failure, pneumonia, and stroke.

Each of the indicators of appropriate care, said Jencks, "related to a condition that causes significant morbidity and mortality for Medicare beneficiaries, with [each indicator having] a strong professional consensus that this service will save lives or reduce morbidity."

Jencks and colleagues at HCFA defined appropriate care in terms of 24 well-accepted quality indicators, such as preventing stroke by prescribing warfarin to patients with atrial fibrillation. The researchers relied on data collected in 1997 through 1999 from inpatients’ medical records, Medicare claims for some ambulatory care services, and government surveys of immunization rates. Fourteen of the indicators pertained to drug therapy.

"For the typical measure," said Jencks, "about 70 percent of Medicare beneficiaries who had no contraindication to the service actually received it."

To illustrate excellence in medical care, Jencks pointed to the use of aspirin after an acute myocardial infarction—noted for about 85 percent of patients in half the states—and the avoidance of sublingual nifedipine by patients with acute stroke—95 percent of patients in half the states. In contrast, half of the states screened at most 11 percent of pneumonia patients for receipt of the pneumococcal vaccine. "There is huge room for improvement," noted Jencks.

The JAMA article includes a table that breaks down, state by state, the percentage of patients who received the indicated care when deemed appropriate. For the two indicators that involved time to treatment—minutes from arrival at the hospital to start of angioplasty or thrombolysis therapy—median numbers, rather than averages, were reported.

A close look at the table reveals only one indicator with a score of 100 percent: avoidance of sublingual nifedipine in Wyoming. Scores went as low as 4 percent: pneumococcal vaccine screening of pneumonia patients in Arkansas, Florida, and Louisiana.

Jencks said HCFA chose to report its results state by state in order to urge a response from people and organizations that can do something about improving the situation. "Without state-by-state data, people would tend to say ‘there’s a national problem—but not in our state.’"

Improvement through collaboration

To show how collaboration can improve medical care, HCFA invited ASHP and three other organizations to enlist speakers to describe their quality-improvement projects. The other organizations represented cardiologists, hospitals, and the peer-review organizations contracted by HCFA to undertake quality-improvement projects.

Thomas S. Sisca, manager of clinical services at Shore Health System in Easton, Md., described the anticoagulation clinic that pharmacists have run, with referrals from physicians, for inpatients and outpatients since 1972. About two thirds of the health system’s patients are covered by Medicare.

Outpatients visit the clinic three or four times a year, on average. Although Sisca originally anticipated the clinic handling 75 to 100 patients, the pharmacists now manage the anticoagulation therapy of about 680 patients—24 hours a day, seven days a week. Sixty-eight percent of the clinic’s patients take warfarin because of atrial fibrillation, a transient ischemic attack, or a stroke. Several patients are nearing 100 years of age, he said.

Collaboration between the physicians and pharmacists resulted in warfarin or antithrombotic therapy for 87 percent of the health system’s Medicare beneficiaries discharged with a diagnosis of atrial fibrillation, acute stroke, or transient ischemic attack, said Sisca. This determination was made by Delmarva Foundation for Medicare Care, the peer-review organization covering Maryland, on the basis of nine months’ worth of hospital discharges in 1999.

According to the JAMA article, the overall rates in Maryland were 54 percent for the atrial fibrillation indicator and 82 percent for the antithrombotic indicator. Sisca said he believes that his hospital scored better than the overall state numbers because physicians and pharmacists collaborated to improve the quality of patient care.

Bleeding-related adverse effects are rare among the patients managed by the anticoagulation service, said Sisca. Only 1.3 percent of the patients have had a major bleeding event, 2.2 percent have had a minor bleeding event, 0.9 percent have had a thromboembolic event, and 2.2 percent have been hospitalized because of the bleeding-related event.

Sisca’s anticoagulation clinic does not receive payments from Medicare, because federal law does not identify pharmacists as "providers." He said the health system and hospital administration deemed the anticoagulation management service important enough to fund, but direct reimbursement will be an issue to consider.

Kim A. Engle, a cardiologist at the University of Michigan Medical Center who also described a successful quality-improvement project, said that pharmacists must be able to bill for their anticoagulation management services. He said that at his facility, financial circumstances had prompted a tentative decision to limit monitoring by the anticoagulation management service to only patients with atrial fibrillation. Uproar ensued, Engle said, as everyone realized what would happen to the other patients without the expertise of the service’s pharmacists, nurses, and physicians.