A report on heart attack outcomes recently released by the California Office of Statewide Health Planning and Development has received mixed reviews.
As the watchdog agency for the state's hospitals, the OSHPD has been required since 1991 to publish periodic reports on how patients are treated at hospitals. The requirement is part of an effort to better inform the public about outcomes and a kind of dress rehearsal for the time when report cards will play a significant role in helping consumers select healthcare.
The OSHPD's latest report studied outcomes of heart attack patients within 30 days of admission at more than 400 hospitals statewide between 1991 and 1993.
Critics of the report said there is a sizable gap in data reported by Los Angeles County, which has 8.5 million residents and is the most populous county in the nation. Two of the county's five acute-care hospitals-Olive View-University of California, Los Angeles Medical Center and Harbor-UCLA Medical Center-were not included in the surveys because of the poor quality of data they reported, said Patrick Romano, M.D., professor of medicine at the University of California at Davis and principal investigator for the OSHPD study. For example, neither hospital recorded the exact type of heart attack, making it impossible to adjust cases to reflect risk factors, Romano said.
Olive View and Harbor cover much of the Los Angeles County's northern and southern suburbs and constitute one-third of the beds in the county.
Even among the three county hospitals that did report, there appears to be a dearth of data. Only 505 heart attack cases were reported during three years at Los Angeles County-University of Southern California Medical Center, a 1,157-bed facility and the largest public hospital west of the Mississippi River. Northridge Hospital Medical Center, a private campus in Los Angeles with only 195 beds, reported 509 cases. Long Beach (Calif.) Community Medical Center, with 290 beds, reported 478 cases.
Donald Thomas, M.D., the county's associate director for clinical and medical affairs, said lack of data at Harbor was due to not placing the exact region of the heart attack on reporting forms, a deficiency that has since been corrected.
As for County-USC, a lot of data was thrown out because the identity of many patients was in question.
"A large percentage of patients don't have Social Security numbers, or they were illegal aliens using Social Security numbers or green cards from relatives who are legal residents in order to get their visit paid by Medi-Cal (California's Medicaid program)," Thomas said.
Thomas did provide data for Olive View, but conceded it did not fit the OSHPD's model-among the reasons it was not included in the agency's report.
Romano did not attribute differences in case volume at County-USC vs. other hospitals to reporting problems. However, he conceded that Olive View and Harbor's absence from the survey means that county residents who experience heart attacks-most with low incomes and little or no health insurance-lack sufficient information to determine whether care there is on par with that received by patients elsewhere. Romano's concern has been echoed by other observers in the healthcare community.
"Many people living in Los Angeles County may not be getting the information they need to make informed decisions," said Peter Lee, executive director of the Center for Healthcare Rights, a Los Angeles-based group that advocates expanding healthcare coverage for low-income individuals.
Although concerned, Romano stopped short of equating a lack of data with a corresponding gap in care.
Romano, however, said research conducted by UCLA and the Rand Corp. does suggest more comprehensive record-keeping can be linked to lower mortality rates among Medicare patients hospitalized for heart attacks, stroke or pneumonia. But no thorough study on the subject has been done, he said.
In categories where data are available, patients in the L.A. County hospital system fared relatively well. LAC-USC's mortality rate averaged 12.2% over the three years, although it increased to 12.3% in 1993 from 11.8% in 1991. Yet the 1993 numbers still fell more than two percentage points below the statewide rate.
LAC-Martin Luther King-Drew Medical Center's rate averaged 12.1% overall. In 1993 it was 12.3%, down from 15.4% in 1991.
Statewide, out of 116,174 patients treated between 1991 and 1993, 5,272 patients died-an average mortality rate of 14.5%. Year to year, mortality dropped to 13.9% in 1993 from 15.1% in 1991.
Despite the data problems, many observers consider this report to be far more detailed and informative than previous efforts. In the past the OSHPD regularly has been taken to task for vague reporting.
The OSHPD's investigators agree that heart attack treatments and outcomes have probably changed dramatically since 1993 but insist that the time required to compile data makes a more timely report unlikely in the future. Instead, they vowed to continue refining the data they receive to make it easier to use.
There's no danger that the OSHPD's work would be confused with a copy of reader-friendly Consumer Reports, but with a few page flips, a fairly intelligent layperson can determine which of the state's hospitals are best and worst at treating heart attack victims based on outcomes.
All told, 31 hospitals had below-average mortality rates in one of the two statistical models the OSHPD used. (One focused on patient health at admission; the other factored in health insurance and the hospital's overall ability to provide care.) Ten facilities fared poorly in both models. Seventeen hospitals had above-average performances in one of the two models, and 12 hospitals were above average in both models.