ORLANDO, Fla., Nov. 10 — Doctors have known for a decade that drugs called ACE inhibitors are a cornerstone of care for congestive heart failure, yet a nationwide survey shows that nearly one-third of patients are sent home from the hospital without this lifesaving treatment.
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The report released Sunday documents what many see as a dangerous reality of modern medicine: Doctors often fail to offer, or simply don’t know about, the most basic elements of care for the many conditions they see daily.
Just why doctors do not give patients the treatments experts universally agree work best is not always clear, although those who study the situation say the reasons probably range from forgetfulness and haste to simple ignorance.
In the latest study, Dr. Gregg Fonarow of the University of California, Los Angeles, looked at how often patients hospitalized with heart failure are discharged with four standard kinds of care. He found they are often missing, although this varies widely from hospital to hospital.
“There are certain hospitals in the United States where 100 percent of the patients get this,” he said. “There are others where patients had a better chance of winning the lottery than getting the indicated care.”
More than 1 million admissions are made each year to U.S. hospitals for congestive heart failure, which is becoming even more common as better treatments that help people survive heart attacks leave them with damaged heart muscle.
Large studies finished in the early 1990s convinced specialists that every heart failure patient — with a few clearly defined exceptions — should be on widely available drugs called angiotensin converting, or ACE, inhibitors. The American Heart Association and the American College of Cardiology included the drugs in their formal treatment guidelines in 1995, and the Joint Commission on Accreditation of Healthcare Organizations later agreed.
The newest survey found that 31 percent of patients considered ideal candidates for ACE inhibitors are sent home without them. Even at elite teaching hospitals affiliated with medical schools, more than one-quarter are not given them.
The other findings:
- 72 percent are discharged without receiving a complete set of discharge instructions, as guidelines recommend.
- 69 percent of smokers with heart failure are never told to quit.
- 18 percent do not have the pumping power of their left ventricles measured, a standard indicator of heart failure.
Fonarow noted that doctors can bill insurance companies for measuring ventricle strength but not for writing prescriptions or exhorting patients to give up smoking.
“I don’t think the public understands the huge degree of variation between hospitals,” he said. “People think if they go to a good hospital, they will get all the standard things.”
InsertArt(2065795)He based his findings on discharge data on 54,639 heart failure patients at 260 hospitals between October 2001 and January 2003. The registry is sponsored by Johnson & Johnson’s Scios pharmaceutical unit, which is developing new heart disease treatments. Fonarow presented the results at the heart association’s annual scientific meeting in Orlando.
Dr. Richard Pasternak, head of preventive cardiology at Massachusetts General Hospital, said he believes doctors are actually more likely to follow standard procedures than they once were.
“Things are getting better,” he said. “The question is why they aren’t getting better faster.”
One approach is to set up systems in hospitals that routinely prompt doctors to offer all the standard kinds of care when they admit patients or discharge them. These are like the checklists airline pilots follow before taking off.
The heart association recently introduced its “Get with the Guidelines” program to improve treatment of heart attacks by helping hospitals establish these checklists. Dr. Kenneth LaBresh of MassPRO, the Massachusetts Medical Society’s healthcare quality organization, said the program has already paid off for the first 123 hospitals to join.
He presented data at the meeting showing doctors at these hospitals are more likely to give such accepted treatments for heart attacks as aspirin, beta blockers and cholesterol drugs.
Among other reports at the meeting Sunday:
A study of 3,203 adolescents in rural North Carolina found that 14 percent have at least three signs of the metabolic syndrome, which puts them at increased risk of diabetes and heart disease. These signs are high blood pressure, elevated triglycerides, low levels of the good cholesterol HDL, high insulin levels, high weight and mildly elevated glucose levels in the blood.
A Tufts University study compared four diet books — Atkins, the Zone, Ornish and the Weight Watchers cookbook — in 160 overweight volunteers and found that all reduced weight by 4 percent to 6 percent over one year. All but the Ornish plan significantly lowered the chance of heart trouble as measured by the widely used Framingham cardiac risk score.
A study at the University of Athens found that people who follow a Mediterranean diet, which emphasizes fish, fruit, vegetables, olive oil and little red meat, have significantly lower levels of C-reactive protein, a sign of general inflammation in the bloodstream. Many researchers think inflammation is a common cause of heart attacks.
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