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Are senior citizens receiving
the health care services they need?
Not always, suggests
one recent study, although progress is being made. "Health
care in the United States can be improved substantially,
and even people with apparently good access to care
receive care that falls far short of what it could be,"
according to the authors of "Change in the Quality
of Care Delivered to Medicare Beneficiaries, 1998-1999
to 2000-2001." The study appeared in the January
15, 2003, Journal of the American Medical Association.
Dr. Stephen F. Jencks,
Dr. Edwin D. Huff, and Dr. Timothy Cuerdon compared
two government reports on 22 common tests or treatments
(referred to as "quality indicators") in the
areas of cardiology; stroke; pneumonia; immunizations;
breast cancer; and diabetes. The government reviewed
medical records of fee-for-service Medicare beneficiaries
from each of the 50 states, Puerto Rico, and the District
of Columbia. New Jersey didn't fare well in the report,
ranking 43rd in delivery of these services, although
progress was made in preventive measures. (Incidentally,
as of 2001, approximately 1 million New Jerseyans over
age 65 were enrolled in the Medicare program.)
Arguably, the study applies
more to health care policy than direct patient care,
but it's a reminder that senior citizens and/or their
caretakers need to be informed health care consumers.
Below, physicians from University Hospital comment on
some of these quality indicators and suggest ways patients
can be better health care advocates.
Heart
Attack
Aspirin is a simple,
inexpensive drug with many benefits, and for 20 years,
cardiologists have recognized aspirin's virtues and
relatively low risks.
Two of the quality indicators
for patients who've had a heart attack, or myocardial
infarction, involve aspirin: that aspirin be given to
the patient within 24 hours of admission and that aspirin
is prescribed when the patient is discharged. "Absolutely
and without a doubt, these indicators should be followed,"
says Dr.
Merwin Richard, director of the cardiac catheterization
lab at University Hospital and an assistant professor.
"Patients who have had a heart attack can reduce
the chance of a second attack by 20 percent simply by
taking an aspirin a day."
Dr. Richard says the
other heart attack-related indicators are right on target,
also. Beta blocker, to be given within 24 hours of a
heart attack patient's hospital admission and prescribed
at discharge, reduces the workload on the heart. Every
heart attack patient who smokes should receive smoking
cessation counseling while in the hospital (smoking
doubles the chance for another heart attack), and for
those patients who show signs of damage to the heart's
left ventricle, ACE inhibitors should be prescribed
at discharge. And yet, only 65 percent of the heart
attack patients throughout the state were prescribed
aspirin at discharge, and a mere 31 percent of the smokers
received information about how to quit.
If these indicators are
so widely agreed on, why did New Jersey fare so poorly?
"These were oversights that should not have occurred,"
says Dr. Richard. "New Jersey's overall ranking
of 43rd was pathetic. We need more educational programs
for doctors and patients within the state so that these
simple, basic things are re emphasized."
Heart attack patients
or their caretakers should take other measures that
are not listed as quality indicators. "When a patient
is experiencing symptoms of a heart attack and the ambulance
comes, ask to be taken directly to a hospital where
acute myocardial infarction primary angioplasty is performed,"
says Dr. Richard. Only about 20 percent of hospitals
nationwide offer angioplasty, a procedure that uses
a balloon to widen the blocked passageway in the heart.
If the patient is taken to a hospital that does not
perform angioplasty and then the decision is made to
transfer the patient to one that does, valuable time
is wasted. The optimal window of treatment is within
12 hours of onset of symptoms and less than 90 minutes
after the patient is diagnosed with a myocardial infarction.
Most hospitals that offer
angioplasty, like University Hospital, are affiliated
with major medical schools.
After the patient has
recovered, says Dr. Richard, it's important to follow
up with cardiac rehabilitation. "From the patient's
perspective, rehabilitation is hard work. He or she
might have to go to rehab every day for weeks, but it's
the only way to get them back to the mainstream."
Stroke
Stroke, or a "brain
attack", occurs when blood flow within the brain
is blocked, typically by a blood clot. It is the third-leading
cause of death in America and the top cause of disability
in adults, often resulting in paralysis, memory loss,
and speech and language problems.
Atrial fibrillation (AF)
is a heart condition that can lead to a stroke. During
AF, the heart's two upper chambers quiver rapidly instead
of beating in a regular rhythm. If blood within the
chambers pools instead of being pumped out, a clot can
form, travel to the brain, and cause a stroke.
One of the study's quality
indicators calls for warfarin, a blood thinning agent,
to be prescribed for patients diagnosed with AF. Dr.
Patrick Pullicino, chairman of the department of
neurosciences at New Jersey Medical School and a leading
expert in stroke, strongly agrees. "Warfarin is
the only indication scientifically proven to reduce
the risk of stroke in patients with atrial fibrillation,"
he says. "It does so substantially, by about 50
percent."
Dr. Pullicino believes
there's something all senior citizens should know how
to do: take their pulse. "Atrial fibrillation produces
an irregular pulse rate. If people learn to take their
pulse and do so regularly, they'll be able to tell the
difference between a normal and abnormal pulse,"
he says. An irregular pulse is a danger signal and possibly
a precursor to stroke, so anyone who detects an abnormal
pulse should immediately seek medical care. (To learn
how to take a pulse, ask a doctor or a nurse, or visit
www.strokeheart.org/CYPA/check.html for information
about the Check Your Pulse America public education
program.)
Pneumonia
Pneumonia is an infection
of the lungs that is most commonly caused by bacteria
or a virus. The Medicare quality indicators call for
antibiotics to be given to patients in whom pneumonia
is suspected within eight hours of their arrival at
a hospital. Dr.
Mark Johnson, chairman of family medicine at New
Jersey Medical School, says that's for a good reason.
"The vast majority
of elderly patients with pneumonia are admitted through
the emergency room and are quite sick: their symptoms
can include fatigue, fever, cough, and shortness of
breath," he says. "It's important to treat
pneumonia with an antibiotic as rapidly as possible,
because if the source is bacterial yet antibiotics are
delayed, the chances for serious complications increase."
The patient should have a blood culture before the antibiotic
is given—another quality indicator—because in advanced
cases of pneumonia, the infection spreads to the blood.
If the blood is drawn after an antibiotic is given,
explains Dr. Johnson, it could produce a false negative
result.
Seniors over age 65 can
help protect themselves against one type of bacterial
pneumonia, says Dr. Johnson, by having a pneumococcal
immunization every five years. The quality indicators
advise assessing whether the patient has had the vaccine,
and if not, administering it every five years. The vaccine
might not prevent an elderly person from contracting
pneumococcal pneumonia, but it can help reduce the complications.
Whenever an elderly person
is very sick and is taken to a hospital, a family member
or caretaker should bring all of the patient's medications
along. "Bring as much information as possible to
the hospital," advises Dr. Johnson.
Influenza
Vaccination
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Dr. Debra Goldson-Prophete
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Medicare patients 65
and older should receive an influenza immunization every
year; according to the study, only 68 percent of New
Jersey seniors received the vaccine. This is one quality
indicator where doctors say they know why compliance
isn't 100 percent. "We can offer the flu shot to
patients, but we can't make them have it," says
Dr. Johnson. "The most common reason patients refuse
it is that they believe having the flu shot will 'give'
them the flu."
And yet, seniors are
one group of people who should get a flu vaccination
each year, says Dr.
Debra Goldson-Prophete, assistant professor of medicine
at New Jersey Medical School and interim medical director,
UMDCare. "Older people are particularly vulnerable
to influenza, which accounts for about 114,000 hospitalizations
and 36,000 deaths due to complications each year,"
she says. "An immunization is needed each year
because there are many strains of influenza, and each
year a new vaccine is developed."
The vaccine is between
70 percent to 90 percent effective, but even if an immunized
person comes down with influenza, he or she will be
less likely to develop serious complications.
As for the patient who
gets sick following a flu vaccine, Dr. Goldson-Prophete
says, "It's probably a common cold that has similar
symptoms as the flu."
Breast
Cancer
A mammogram can indicate
the presence of abnormalities in the breast one to three
years earlier than self breast exam or a breast exam
performed by a doctor. The earlier breast cancer is
found, the more treatable it is. By the study's criteria,
all female Medicare patients between the ages of 52-
69 years of age should have a mammogram at least every
two years.
"Mammograms are
very important; they reduce the risk of dying from breast
cancer by about 30 percent. Most doctors agree that
women in a slightly wider age range between 50-74 should
have a mammogram every one to two years," says
Dr. Goldson-Prophete. "However, a woman's family
history can influence how soon mammography is recommended.
If a female relative had breast cancer in her 30s, we'd
want that woman to begin getting a mammogram at a younger
age than the general population."
Diabetes
About half of all diabetics
are over age 60, and of people over age 75, approximately
20 percent have diabetes. It's possible to have diabetes
and not know it; the American Diabetes Association says
that's the case with about one-third of the 17 million
diabetics in the U.S. Diabetes is a growing problem;
the World Health Organization estimates that by 2025,
300 million people worldwide will have diabetes.
Once a person is diagnosed,
certain tests can help determine if his or her diabetes
is being well controlled by diet and/or medication.
The study's quality indicators for patients with diabetes
include an eye exam at least every two years; a lipid
profile to check cholesterol levels at least every two
years; and a blood test known as Hemoglobin A1c at least
once a year.
Diabetic retinopathy,
which damages the tiny blood vessels in the eye's retina,
is a leading preventable cause of blindness. In the
early stages, it can be successfully treated with laser
therapy. "Diabetic patients should have an eye
exam every year, rather than at least every two years.
Not only does the exam monitor for eye disease, but
it gives the primary care doctor a good idea of how
well controlled the diabetes is," says Dr. Goldson-Prophete.
"Reading the eye chart at the mall or community
health fair doesn't count. People with diabetes need
to be seen by an ophthalmologist, a medical doctor who
specializes in eye diseases."
People with diabetes
typically use a "finger stick" test daily
to monitor their blood sugar levels. Another blood test,
the Hemoglobin A1c, provides physicians with a long
term perspective of blood sugar control up to three
months. Here's how it works. Extra glucose binds to
the hemoglobin in red blood cells. The Hemoglobin A1c
test measures the percentage of glycated hemoglobin
in the blood, with 7 percent considered the top of the
acceptable range. "With every 1 percent reduction
on a Hemogloblin A1c test, the risk of developing diabetes-related
complications such as nerve or kidney damage goes down
40 percent," says Dr. Goldson-Prophete.
While the quality indicators
advise a minimal yearly Hemoglobin A1c test, Dr. Goldson-Prophete
says frequency all depends on the patient. For someone
whose diabetes is poorly controlled, the test might
need to be done every two to three months; the patient
who is well controlled might have it done twice a year.
When a patient with diabetes
also has elevated cholesterol levels, he or she has
an increased chance of heart attack or stroke. The lipid
profile measures cholesterol levels. Simply by improving
lipid levels, a patient decreases the risk of cardiovascular
complications.
There are two tests that
are not on the quality indicator list for diabetes but
should be, says Dr. Johnson. One is an annual foot exam,
preferably performed by a podiatrist with expertise
in treating patients with diabetes. Diabetes can cause
poor circulation; in the feet, that can lead to a downward
spiral of decreased sensitivity, sores or ulcers on
the feet; gangrene; and possibly, amputation. Daily
diligent foot care and inspection by the patient and
at every opportunity, the doctor are key. "If you're
a person with diabetes and your doctor does not have
you take off your socks and shoes at every visit, you're
not being well served," believes Dr. Johnson.
The other test, he says,
is a urine test. Proteins in the urine are the first
indication of kidney damage, a common complication of
diabetes.
Dr. Goldson-Prophete
believes it's not only important for people for diabetes
to have these recommend tests, but to record the results.
"Just as the doctor keeps track of the tests, patients
or their caretakers should, too," she says. "They
should keep records of their cholesterol levels and
the date and value of their last Hemoglobin A1c test.
It's best not to rely on memory, but to write everything
down."
Similarly, notes Dr.
Goldson-Prophete, an elderly patient should bring every
medicine, vitamin, or herbal remedy that he or she takes
to their annual check up. "Seniors often have more
than one doctor, and it's possible that seeing multiple
physicians can result in prescriptions for the same
medicine," she says. "Older people might also
be mistakenly taking prescriptions that have expired
or drugs that interact with each other."
Looking
for a physician who will respect and encourage your
participation in health care decisions? Consider the
New Jersey Family Practice Center at (973) 972-2111
or UMDCare, the internal medicine practice of University
Hospital at (973) 972-8087.
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