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| CRITICAL CHOICE | |
 May 27, 1999 
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Treatment at a hospital that is very experienced in treating heart attacks could dramatically increase your chances of living, a study published in the New England Journal of Medicine said. Elizabeth Farnsworth talks with the lead author of the report, Dr. David R Thiemann, a cardiologist at Johns Hopkins University. |
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High-volume centers. |
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ELIZABETH FARNSWORTH: Dr. Thiemann, briefly tell us who you were studying and what you found.
ELIZABETH FARNSWORTH: And what do you mean by low and high-volume? DR. DAVID THIEMANN: Well, high-volume centers had basically taken care of more than about four Medicare heart attack patients per week or translated into the entire population of patients with heart attack, about one patient per day. The low volume centers had actually less than one patient per week. ELIZABETH FARNSWORTH: And Dr. Thiemann, what do you mean by elderly?
ELIZABETH FARNSWORTH: Before we get into why this might be happening, what's the significance for our viewers who have either had heart attacks or have friends or relatives who have had them? Should they be sure that if an ambulance comes, for example in San Francisco the ambulance is supposed to take you to the closest hospitals, we checked on it, should they be sure that doesn't happen, that they go to a hospital that has a higher volume of treatment of heart attack victims? DR. DAVID THIEMANN: I don't think this study has implications for individual patients for several reasons. The most important thing for a patient who is having what they think might be a heart attack is simply to call 911 and get into an ambulance, regardless of where the ambulance is going. The other reason is that this is primarily an issue for emergency medical system policy makers and for politicians. It suggests that emergency medical system policy perhaps could be revised. But unfortunately, or fortunately, patients don't have control over where the ambulance is going to take them. ELIZABETH FARNSWORTH: How would you revise the emergency policy system?
ELIZABETH FARNSWORTH: And we should be clear here for the record, there was an editorial in the "New England Journal of Medicine" that accompanied your article, that this study, your study's looking at averages, right? It doesn't mean that a given hospital with low volume heart attack treatment is not -- does not do very well treating heart attacks? Is that right? DR. DAVID THIEMANN: That's absolutely correct. ELIZABETH FARNSWORTH: Is this why individuals shouldn't try to make their own decision? DR. DAVID THIEMANN: Yes. There are many excellent low-volume hospitals. Part of the problem, however, is there's sort of a statistical Catch-22 here in that in hospitals with very low volume, it's impossible to have an adequate sample size to even tell whether they're good or bad. And this is one of the fundamental debates in quality assurance, in the debate about whether patients should be taken directly to a bigger hospital, or whether we ought to try to improve the quality at smaller hospitals or try to identify which hospitals are best regardless of volume.
DR. DAVID THIEMANN: One of the issues raised by this study is how to identify in the field patients who have a high likelihood of having a heart attack. If paramedics using either automatically interpreted electrocardiograms or using a simple questionnaire could identify patients who were likely to be having a heart attack and take only those patients to the higher volume centers or only the very sick patients to the higher volume centers, we might be able to maximize the benefit without overwhelming the system. |
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Practice makes perfect? |
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ELIZABETH FARNSWORTH: Dr. Thiemann, why do you think the high-volume hospitals do so much better? Is it just that practice makes perfect?
ELIZABETH FARNSWORTH: Excuse me. In other words, the way that use those makes some difference? DR. DAVID THIEMANN: Yes. ELIZABETH FARNSWORTH: Okay. DR. DAVID THIEMANN: But most of the difference isn't explained by any of the individual practice variations that we were able to measure. It suggests that the experience not just of the doctors, but of the entire health care team, from the emergency room through the coronary care unit nurses to the tension in additions in the operating room and the catheterization laboratory, is key, because in this analysis, we included the specialty of the physicians, and even a cardiologist at a low-volume hospital does not have as good an outcome for his patients as cardiologists at high-volume hospitals. ELIZABETH FARNSWORTH: Do most cities have high-volume hospitals, and what about rural areas?
ELIZABETH FARNSWORTH: Do you recommended that hospitals be developed which are essentially cardiac attack units? They have like a trauma unit. If you now have a severe trauma, you may be taken to a hospital because it has this severe trauma unit. Do you think that should happen with heart attacks too?
DR. DAVID THIEMANN: This is a fundamental debate within quality assurance
and improvement efforts in medicine. It's sort of whether to bring the
mountain to Mohammed or Mohammed to the mountain. If experience is what
matters, as seems likely from this study, then merely being at a low-volume
hospital is a severe disadvantage. And it's probably easier for a nurse
or a doctor to maintain their skills and to improve ELIZABETH FARNSWORTH: All right. Well, Dr. Teaman, thank you very much for being with us. DR. DAVID THIEMANN: Thank you. |
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ELIZABETH
FARNSWORTH: The new research, published today in the New England
Journal of Medicine, found that heart attack patients stand a better
chance of surviving if they're taken, not just to the closest hospital,
but rather to one with lots of experience with heart attacks. The lead
author of the report joins us now. He is Dr. David Thiemann, a cardiologist
at Johns Hopkins hospital. 
DR.
DAVID THIEMANN, Johns Hopkins Hospital: We were studying elderly patients
who had the confirmed diagnosis of heart attack. Medicare, the Health
Care Financing Administration, collected data in 1994 and 1995 on essentially
every elderly patient who had a heart attack during that period and
put together a large database that we were able to analyze. We found
that patients who had heart attacks and were taken to low-volume centers
did much worse than those who were taken directly to high-volume centers,
even after adjusting for technology and the doctor's specialty and every
clinical factor involving the patient. 
DR.
DAVID THIEMANN: The Medicare database's patients over 65 only but our
findings probably apply to younger patients, as well. If anything, there
was greater benefit among the younger patients than among the very elderly.
So that although overall there was about a 17 percent difference between
patients at the lowest and the highest volume hospitals, in the youngest
age group, the 65 to 69-year-old patients, the difference went to as
high as 38 percent. 
DR.
DAVID THIEMANN: I think there are two answers. One is that for patients
who are obviously having a heart attack, emergency medical system people
and paramedics may consider taking them directly to a high-volume center,
if the transit time isn't significantly different. For patients who
may be having a heart attack but don't have the obvious diagnosis, the
situation gets much murkier, because if the ambulance took everybody
who might be having a heart attack to high-volume centers, they'd quickly
overwhelm every big hospital in the country. 
ELIZABETH
FARNSWORTH: And is this sort of your research so far a beginning point
for more research, I gather? 
DR.
DAVID THIEMANN: It looks as if part of the difference is due to individual
practice characteristics, particularly the use of aspirin and beta blockers,
which explain about a third of the difference. 
DR.
DAVID THIEMANN: Part of the problem I think is that in the United States
there is a lot of economic pressure for new drugs and new devices, but
we have not invested large sums of money in the emergency medical system.
So in Europe, for example, it's fairly common to give clot-busting drugs
to heart attack patients in rural areas in the field before they ever
get to the hospital. That's very rarely done in this country because
we haven't invested in the training and the infrastructure needed to
do so. One of the surprising findings in our study is that simply living
in a rural area is an independent risk factor for worse survival after
heart attack. And that suggests that this is a particular area that
might be targeted by health service interventions.
DR.
DAVID THIEMANN: The trauma analogy is interesting and seductive, but
it doesn't apply to cardiac disease for a couple reasons. One is that
there are many more cardiac patients than trauma patients. Another is
that the cardiac patients tend to have a lot of other problems. So I
think the notion of stand-alone hospitals that do nothing but hearts
is probably not destined to survive. However, I think the notion of
large, high-volume centers that have a special expertise in cardiac
disease in addition to taking care of a range of general patients probably
is something that deserves serious consideration. 
ELIZABETH
FARNSWORTH: And you have touched on this throughout, but I gather you
aren't sure yet whether low-volume hospitals could be brought up to
par with the high-volume hospitals if certain things are taught or certain
treatments are begun.