By
Richard A. Knox, The Boston Globe
Call
it the failure of prevention. It may be American health care's
biggest flaw. And its consequences are especially dire for elders.
Every day, doctors are failing to prescribe the tests, pills,
and lifestyle changes known to lower mortality and avoid needless
suffering. Despite libraries full of weighty tomes telling physicians
how to minimize the toll of heart disease, high blood pressure,
cancer, diabetes and other killers, medicine's full potential
lies tantalizingly out of reach.
``There
are so many gaps in care that are so maddening,'' says Dr. Thomas
H. Lee, whose job is to figure out how to fill those gaps for
the more than 1.2 million patients who get their care through
Partners Community Healthcare in Massachusetts.
The
care gaps are ``pretty pervasive, pretty striking and pretty distressing,''
agrees Dr. Joseph P. Frolkis of the Cleveland Clinic. ``People
are struggling with this problem all across the country,'' adds
Dr. David E. Wennberg of the Maine Medical Assessment Foundation
and Dartmouth Medical School.
Study
after study documents the problem. Last month, for instance, Wennberg
and his Dartmouth colleagues published an annual ``atlas'' of
US health care for elderly Medicare beneficiaries showing, among
other things, that:
Fewer than one-third of older American women get mammograms every
two years, as they should; only 12 percent of elders are checked
in a two-year period for colorectal cancer; and among elderly
diabetics, fewer than half have eye exams to detect early disease
that leads to blindness if left untreated.
That
just scratches the surface of what many call the ``prevention
gap.'' When people hear ``prevention,'' they often think of lifestyle
changes such as smoking cessation, healthier diets, weight loss,
and regular exercise. These are matters of personal habit that
are largely the patient's responsibility, ideally with a nudge
from the doctor.
But
there is a large realm of prevention that requires medical intervention.
One sort, which doctors call ``primary prevention,'' encompasses
measures to detect early disease in individuals without symptoms.
This includes mammography for breast cancer; rectal exams and
monitoring of enzyme levels to pick up prostate cancer; and diagnostic
tests for colon cancer. Primary prevention also includes vaccinations
against influenza and pneumococcal pneumonia.
The
most glaring lapses in preventive medicine, however, involve ``secondary
prevention,'' which focuses on the millions of Americans with
ailments such as high blood pressure, heart disease, and diabetes.
Overwhelming evidence shows the health care system is doing a
poor job of applying measures known to prevent serious disability
and death -- often things as simple as prescribing a beta-blocker
drug following a heart attack.
Take
high blood pressure, for instance. With effective control through
diet, exercise, and medication, its worst downstream effects --
heart attack, stroke, and kidney disease -- can be reduced by
as much as 50 to 75 percent. Yet among the 50 million Americans
with hypertension, the proportion who are aware of their problem
has actually declined over the past decade.
Some
of the most disturbing recent evidence on the prevention gap concerns
heart disease, the nation's leading killer.
Dr.
Thomas Pearson, chairman of preventive and community medicine
at the University of Rochester, recently concluded a study of
5,620 patients admitted to 50 US hospitals because of a heart
attack, worsening cardiac symptoms, or the need for a coronary
bypass or angioplasty procedure. These people are at high risk
of death or disability.
Such
patients typically have at least two major risk factors -- red
flags signalling the need for medical intervention. But Pearson
found that heart specialists typically did not note risk factors
in medical records.
Only
half of those with high cholesterol had it recorded, along with
fewer than half with diabetes, and less than a third with high
blood pressure, pearson reported at a recent conference in Waltham
sponsored by the American Heart Association.
The
breakdown was not simply a matter of record-keeping. At hospital
discharge, only 42 percent of these typical heart patients went
home with recommendations for cholesterol-lowering drug treatment.
This is despite strong evidence that lowering ``bad cholesterol''levels
reduces the chance of a second heart attack or death by 25 to
40 percent -- a benefit, Pearson notes, that ``rivals or exceeds''
costly bypass and angioplasty procedures.
UNCHECKED
DIABETES
Such
missed opportunities are not restricted to heart disease. ``The
majority of diabetes patients referred to me have not had most
of the five or six things that should be checked regularly,''
says Dr. David M. Nathan, chief of Massachusetts General Hospital's
diabetes center. ``Sometimes it's pretty frightening.''
``There's
a kind of disconnect,'' observes the Cleveland Clinic's Frolkis.
``Physicians, when interviewed, support the idea of prevention
and are often quite knowledgeable about the content of specific
guidelines. But they follow them only 20 to 60 percent of the
time.''
Not
all the fault is the physician's. The patient is to blame, of
course, if she or he fails to take the prescribed medication or
follow dietary orders. Of the three billion US prescriptions written
annually, only half are thought to be filled and taken as directed.
Nearly 90 percent of patients with hypertension taking their pills
within a year.
Yet
is this always the patient's fault? Among 3,260 Medicare enrollees,
more than a third of English-speakers and 54 percent of Spanish-speakers
were found to be ``medically illiterate'' in a recent study in
the Journal of the American Medical Association.
``Medically
illiterate'' doesn't necessarily mean patients can't read, but
rather that they cannot grasp doctors' instructions and health
messages.
``We're
not doing a good job of communicating with patients,'' says Dr.
Harlan Krumholz of Yale University. ``For instance, I recently
saw a 77-year-old black woman with a history of heart attack.
She didn't know what blood pressure was, what her blood pressure
target should be, what relationship blood pressure has to heart
disease. She couldn't name foods high in fat, salt, or cholesterol.''
A WORD OF ADVICE
Regardless
of patients' education level, research shows they need clear information
and encouragement to stick with chronic treatment regimens.
Cardiologist
Richard Pasternak and his colleagues at Massachusetts General
Hospital are launching a program to telephone elderly patients
who have not filled their prescriptions. And Cleveland Clinic
doctors are beginning to send heart patients home from the hospital
with written treatment instructions, since they found that heart
specialists weren't addressing post-hospital treatment -- even
when prompted.
Many
believe major gaps in preventive care will narrow only when patients
take a more active role, such as pressing their doctors about
a mammography or prostate exam, a blood pressure reading, cholesterol
test, or an eye exam if they haven't had one in awhile.
Meanwhile,
experts are doing more than wringing their hands over the situation.
Momentum is building behind major efforts to close health care's
prevention gaps. But those who have tried warn that it won't be
easy.
COUNTING
HEADS
The
argument has often been made that managed care plans will improve
care because they have a stake in keeping patients healthy --
especially within ``capitated'' plans that put doctors at financial
risk if their patients fall ill and consume more resources. But
many now doubt that premise.
``Capitation
has not been a friend of prevention,'' says MGH's Pasternak. Tina
Brown Stevenson, a Partners vice president, agrees: ``No one wants
to invest in prevention. The payoff is way down the line when
someone doesn't have a stroke or kidney disease. Most health plans
say, `In three years the patient will be with another plan.' ''
Yet there is some evidence that health professionals do respond
to concerted efforts -- especially when the stakes include monetary
rewards and public disclosure of their performance. When Tufts
Health Plan offered Partners a $400,000 bonus if they could raise
the rates of mammograms and flu shots among the elders in the
Tufts' Secure Horizon's plan, Partners doctors hustled -- and
exceeded the 20 percent improvement target.
There are major efforts at the national level too. The federal
Health Care Financing Administration, which runs Medicare, is
embarking on a campaign to get doctors to prescribe more aspirin
and beta-blocker drugs to heart attack patients. ``We think we
might be able to reduce mortality from a repeat heart attack on
the order of 3,000 lives a year at the end of the three-year period,''
says Dr. Stephen Jencks, the agency's director of quality improvement.
And
the National Committee on Quality Assurance (NCQA), a voluntary
group that tries to improve care in health maintenance organizations,
has begun to require health plans to measure and publicly report
what proportion of their subscribers have their cholesterol below
specified targets and, next year, how many have their blood pressure
under control.
Because
competition among HMOs is so keen, the hope is that public disclosure
of performance on these measures will get care providers' attention
as nothing else has. ``In terms of public health, we all feel
this will have more impact than anything we've been involved with
in our careers,'' says Lee, the Partners official, who is on the
NCQA committee. ``These measures will save many, many lives.''
Next
Article