Released, but Still at Risk of Dying

A medical riddle

Heart patients do not receive vital treatment instructions upon being released from government hospitals, according to a study released here for the first time. Despite the severity of the findings, the Ministry of Health and the kupot holim health maintenance organizations (HMOs) are not sufficiently monitoring medical treatment in the hospitals. And this isn't the first time that health care institutions are ignoring the problem

More than half, 53 percent, of all patients suffering from coronary heart disease and who were treated in 1997 at the government-run, Wolfson hospital in Holon did not receive from the hospital's doctors all of the necessary instructions for the drug therapies meant to prevent their disease and reduce their risk of dying. At the government's Sheba Medical Center at Tel Hashomer, findings showed that that same year 28 percent of patients did not receive all the pertinent instructions for drug therapies to treat the diseases they had. The study by Tel Aviv University's Faculty of Management was conducted by, among others, four doctors, two of whom are senior doctors at the Maccabi HMO and are also working on a master's degree in health system management.

Heart disease is one of the most common and deadly diseases in the Western world and the findings indicate that a large number of patients did not receive drugs that could have substantially improved their medical condition and even prevented their deaths.

The study, published here for the first time, compared the treatment instructions issued to Maccabi members hospitalized in the internal medicine departments and intensive care unit at Wolfson hospital to those given by doctors in the same departments at Sheba Medical Center. The study also found that instructions given that year by doctors at Sheba hospital to male patients were closer to the acceptable standard than those given to women (at Wolfson, there was no discernible difference between the treatment provided to men and women). These findings reinforce the recurring claims of recent medical studies that women are discriminated against when receiving medical treatment, primarily for heart diseases.

Although the study was conducted for academic purposes, it was forwarded in 1999 to the Maccabi HMO's management - the medical director, Prof. Alexander Aviram and the director general, Shabtai Shavit (who has since been replaced by Prof. Shuki Shemer). The study's authors even advised Maccabi to set up a system to monitor the medical treatment of HMO members in the hospitals and at the same time to urgently work on reassessing the quality of medical care provided to Maccabi members at Wolfson hospital, "and this should even precede or be unrelated to any of the HMO's overall attempts at quality control."

However, Maccabi's management sufficed with forwarding the study to the director of Wolfson hospital, Dr. Moshe Mashiach, and did not conduct additional similar tests at Wolfson or other hospitals. Consequently, a study that showed huge differences in the quality of medical care at two hospitals located near each other in the center of the country and which should have served as a model for Maccabi's medical oversight was not really addressed by the HMO's senior management.

However, Maccabi is not the only HMO that does not systematically and regularly monitor the quality of the medical care its members receive. The other HMOs also do not do so. And the Health Ministry - whose legal and public obligations should have required it to be at the forefront of medical oversight in Israel - does not systematically and regularly monitor the treatment provided at healthcare institutions in Israel. There is no such oversight of mortality rates, incidence of disease or infections, despite repeated criticism on this matter from the state comptroller and elsewhere.

Previous studies in Israel produced equally severe findings. In 1989 a similar study conducted at Be'er Sheva's Soroka hospital (owned by the Clalit HMO) found that between 37 and 43 percent of heart disease patients treated there that year did not receive appropriate drug therapies. In 1990, 34 to 54 percent of heart patients hospitalized in the two internal wards at Sheba did not receive proper instructions for the drugs with which they were being treated. According to the 1997 study, among Maccabi members there was a noticeable improvement in the instructions for taking drugs given by doctors at Sheba to patients in the internal wards. This reinforces the need to maintain constant oversight on the quality of care and draw the necessary conclusions.

However, the 1989 findings regarding Clalit HMO patients also, like the 1990 findings about Sheba patients and the 1997 findings about Maccabi members, did not prompt the Ministry of Health and the HMOs to institute proper oversight systems.

Missing information

The diseases in question are among the main causes of mortality in Western countries. For example, there is coronary heart disease, and afflicted patients suffer an improperly functioning or damaged myocardium as a result of narrowing or blockage of the coronary artery - the artery that supplies blood to the heart. Among patients, those who had a myocardial infarction were at the greatest risk. In the United States, for example, approximately 1.5 million people suffer each year from a myocardial infarction, and around one million survive. These patients receive medical and drug therapies that prevent a worsening of their condition.

The drugs used to treat the ailment include aspirin to prevent blood clots. Numerous medical studies cite proofs as to the effectiveness of aspirin. Among other things, it has been found that the use of the drug has led to a drop of up to 61 percent in the risk of suffering a myocardial infarction and death as well as a 20 to 30 percent drop in the risk of suffering a brain aneurysm. The drug has relatively few side effects and is considered economically feasible. Therefore, it is common to use aspirin to treat all patients who had myocardial infarctions, except in cases where there are specific instructions not to use the drug.

Other internationally-recognized advice is the prescription of drugs to lower blood pressure of patients who have had a myocardial infarction: beta blockers (such as Deralin and Normitan) and eca-suspending drugs such as Convartin. A series of studies has proven both the medical and economic effectiveness of these drugs in treating heart disease.

The study looked at the instructions for taking drugs that doctors wrote from July to December 1997 on the release forms of patients at Wolfson and Sheba hospitals. The survey reviewed release forms for patients aged 35-80 hospitalized after a severe myocardial infarction, angina pectoris, ischemic heart disease or chest pains, with no medical restrictions barring them from receiving the drugs surveyed in the study.

It turned out that not all of the patients at Wolfson and Sheba received instructions on a drug therapy that has already been proven effective and capable of preventing heart disease. However, there was a noticeable difference between the two hospitals.

At Wolfson, the drug therapy instructions written in the release forms of 151 heart disease patients were reviewed. Only 47 percent of the forms included the necessary instructions. Some 36 percent of the patients with angina pectoris did not receive instructions to take aspirin; 64 to 86 percent of patients after a myocardial infarction did not receive instructions on being treated with other vital drugs.

The instructions for using drugs prescribed to 316 patients at Sheba hospital were also checked. Only 28 percent of the release forms included the necessary instructions. Fourteen percent of the patients with angina pectoris were not instructed to take aspirin, as they should have been; 12 to 50 percent of the patients after a myocardial infarction were not instructed regarding vital drugs that should be taken.

Furthermore, at Sheba, 74 percent of the men received full instructions whereas only 65 percent of the women did. According to medical literature, the reason doctors refrain from giving suitable recommendations for drug therapies stems from an unfamiliarity with or disagreement with the recommendations and the absence of an organizational structure (such as procedures, training and control) to guarantee implementation of the recommendations. However, the study did not review the reasons why the doctors at Wolfson or Sheba refrained from writing down the recommended drug therapies.

The study found that the failure to prescribe drugs to heart patients "has serious economic and health implications for Maccabi and the economy - the significant differences in the release recommendations at the two hospitals reviewed obligates Maccabi to recognize that it receives different goods from different hospitals." Maccabi was also advised to look at the quality of medical care at other hospitals not reviewed in this study and to organize outside the hospitals to ensure appropriate medical care for HMO members with heart disease.

Insufficient oversight

The study's authors advise Maccabi to take special notice of the differences in the care given to men and women at Sheba in light of findings in the medical literature indicating that heart disease in women leads to more complications and higher mortality rates than among men and that the period from the time the woman sees the doctor until she is diagnosed as suffering from heart disease is longer for women. The study's authors advise Maccabi to tighten its supervision of heart disease prevention methods among HMO members.

Until now, as with the other HMOs, Maccabi's ongoing oversight of treatment that HMO members received at hospitals focused on accounting and managerial oversight on the part of HMO officials. There is also supervision within the hospitals to discern whether a hospitalization is justified, to prevent it from being extended longer than medically required, and to create contact between hospital officials and HMO institutions, in order to shorten the patient's hospitalization and facilitate his return home or transfer to another medical institution. In recent years, Maccabi has also been doing surveys to assess the satisfaction of HMO members with the various hospitals they use; however, thus far, no HMO has done any monitoring of the medical care their members receive.

Prof. Aviram, Maccabi's medical director, has a surprising answer. According to him, "this `study' was of no significance for Maccabi, the findings have exceeded a statue of limitations of around five years and the work was not commissioned by Maccabi but was the initiative of the students themselves." According to Aviram, "Quality control operations to ensure the level of medical care at Maccabi take place regularly." Maccabi does indeed have a smoothly operating department to investigate accidents, errors and medical failures (the risk management department) run by Dr. Rachel Wilf-Meron and Irna Levinhoff. However the department is not a complete alternative to systematic, regular oversight of medical care.

At Wolfson hospital, however, they viewed the survey's findings more seriously. The hospital, it was reported, did have numerous reservations about the way the survey was conducted and presented, but the management took various steps to investigate and monitor the findings of the study to ensure suitable medical care according to standard medical practices.

Wolfson hospital also reported that among the other issues discussed were the findings of a meeting of the hospital's internal ward, and that a committee of senior doctors was formed headed by the director of the internal ward to constantly monitor and oversee the treatment of heart disease cases. The committee oversees the work of the wards by looking at patients' records and reviewing the treatments being provided for various illnesses. n

The study examined the instructions about medications written on the release forms of heart patients at the Wolfson and Sheba government hospitals in 1997, as they left the hospitals. These forms are intended to summarize the patients' medical condition during their period of hospitalization, the course of their treatment, as well as recommendations for continuing treatment following their release. The people expected to read the release forms are the patients themselves, their family doctors who are meant to provide the treatment and monitor the patient based on the information in the release form, and the HMOs, which also receive a copy of the release form from the hospital.

However, the study made some very grave findings about the doctors' release forms - some of the forms written in the hospital were illegible and many of them lacked vital medical information. The study stated that "most of the forms are handwritten and some of them are almost totally illegible. Most of the forms lack very relevant details, such as the patient's medical history and a list of the drugs the patient was given prior to hospitalization as well as details about the course of his hospitalization and the recommendations made upon his release."

The study's authors, some of the senior doctors at the Maccabi HMO, note that, "Beyond our problems in conducting the survey, this quality control problem raises the question of the possible connection between the quality of the release forms and the quality of the care. We didn't examine this, but we're wondering if, and why, there is still room for incomplete, handwritten medical documentation."

Not long ago, Ha'aretz reported ("The doctor's handwriting was terrible. The patient died," 14 May, 1999) that the illegible handwriting of some doctors is one reason for fatal errors when prescribing drugs. This is also the conclusion of a series of investigations conducted within the health system. Among other things, it was one factor uncovered in the investigation of the death of a 71-year-old man in October 1998, after he received an insulin dose 10 times greater than the dosage he should have received. The insulin was given to him at a Clalit HMO clinic in Ariel.

An investigation of this case revealed that before then, the patient had been hospitalized in an internal ward at Beilinson hospital in Petah Tikvah. In his release form, the ward doctor wrote instructions for the continuation of his treatment. Among other things, he recommended that the man start taking an 8-unit dose of insulin each evening. On the release form, he wrote the standard medical terminology: "8U" (U being the first letter in the word units). Based on the release form from Beilinson, the HMO clinic doctor in Ariel wrote a prescription for insulin. On October 29, the clinic nurse came to the patient's home and gave him an injection of 84 units of the drug instead of eight units. As a result, the patient died.

According to the Clalit HMO's investigative report, "the release form from Beilinson's third internal ward is handwritten and partially illegible and the prescription of 8U was written in such a way that it could have been read as 84." The committee also determined "there were constant shortcomings in Beilinson's links with local community clinics regarding patients about to be released." As a result, the hospital management ordered that patients' release forms be typed, in order to prevent further misunderstandings.