America's elderly often fail to get optimal care for diabetes or the latest treatments for heart attacks, according to two studies of medical practices across the country.
Although the reasons remained unclear, doctors speculated that some physicians may not be aware of new guidelines or -- in the case of heart attacks -- may have trouble identifying patients who could benefit most from aggressive therapy.
The studies, published in today's Journal of the American Medical Association, are the first to evaluate the performance of the nation's doctors and hospitals by comparing Medicare claims data to accepted standards of care.
In the heart study, doctors found that a sixth of patients most likely to benefit from aspirin and more than half who were excellent candidates for a class of drugs known as beta blockers failed to receive them when they were discharged from the hospital.
Additionally, a majority of patients who received clot-dissolving drugs known as thrombolytics waited more than an hour for the drugs after reaching the hospital emergency room -- well past the 30-minute interval in which patients are thought to benefit most.
Doctors have known for years that aspirin, which thins the blood, and beta blockers, which reduce heart rate and blood pressure, can save lives after a heart attack. Thrombolytics limit damage by dissolving the clots in the heart's blood vessels.
"It's not that every patient isn't being treated," said Dr. Robert A. Vogel, chief of cardiology at the University of Maryland Medical Association and an adviser to the federal Health Care Financing Administration, which led the study. "But certainly, there are physicians who are not as 'in tune' with the standards of care that are warranted."
Heart attacks are the leading cause of death in the United States.
The federal agency, which administers Medicare, used data from more than 16,000 hospitalizations in Alabama, Connecticut, Iowa and Wisconsin, but plans to extend its study to the remaining states.
Dr. Vogel said some doctors may be reluctant to treat the elderly with the latest and most beneficial medications because they fear side effects, which are generally more common among senior citizens. The elderly are also more likely to have other illnesses that complicate treatment.
But researchers who conducted the study concentrated on "ideal" candidates for various drugs, eliminating those who might react adversely.
"Heart attack patients generally today are treated aggressively with medical therapy at the best institutions, but it falls off from there," Dr. Vogel said.
Researchers in the diabetes study found that only a small proportion of elderly diabetics were getting recommended tests. The study focused on 98,000 patients from Alabama, Iowa and Maryland who were treated by primary care doctors.
Eighty-four percent weren't getting special blood work, 54 percent weren't seeing an ophthalmologist and nearly half received no cholesterol screening, the study found. The tests are considered essential by physicians who specialize in diabetes.
"The results show that doctors are a long way off from meeting the ideal care standards that they themselves set," said Dr. Jonathan Weiner, professor of health policy and management at the Johns Hopkins School of Hygiene and Public Health. Dr. Weiner, the lead author, said physicians can and should set their own standards.
"But ultimately, society and payers must hold their feet to the fire."
Diabetes, an incurable metabolic disorder that affects 14 millionAmericans, is a major cause of death and disability in the U.S. It is the leading cause of preventable blindness. Dr. Weiner and others said the findings on the elderly patients are also relevant for the under-65 population, about 18 percent of whom are uninsured and therefore receive little primary care.
Dr. David Madoff, chief of endocrinology and metabolism at Good Samaritan Hospital, said preventive medicine is often neglected. That's because insurance companies don't pay for certain tests or treatments, he said, and patients sometimes don't listen or like the recommendations.
One elderly Baltimore woman who has diabetes said she still wishes she had more guidance, even though she sees one of the top doctors in the country.
"I see him twice a year for 15 minutes. I feel that isn't enough," said Ann Morton, 76. The Homeland woman said sometimes doctors expect diabetic patients to be too self-sufficient.
Dr. Bruce Sindler, a Pikesville endocrinologist, said some physicians aren't aware of new guidelines.
But "in many cases, physicians see patients with diabetes and think it's not a big deal," he said.
Researchers plan to use both the diabetes and heart attack studies as models for using claims data to monitor how patients are treated.