With so many patients deferring routine screening or medical attention for their aches and pains, will it eventually be more difficult to give, or too late?

Will treatment be more complex, with longer and poorer recovery, more invasive with longer stays in acute settings, higher risk of infections and other unintended consequences? Will it then be more expensive for everybody?

Might undetected cancer be given time to spread or untreated cholesterol turn into life-threatening artery blockages, or high blood pressure evolve to a stroke?

Lots of questions but few answers with hard data so far, physicians and hospital officials say. The economic downturn is still too short-lived. It depends on how long it lasts, how long patients put off care, and whether the Obama administration will find any broad solutions.

But there is no question that the volume of patients seeking care is down in physicians' offices.

In hospitals, elective procedures are down 31% between the third quarter of 2008 and the third quarter of 2007, according to an American Hospital Association survey last November. Admissions are down 38%. And that can't be anything but harmful to public health.

Patients are putting off regular mammograms, colonoscopies, pap smears, blood sugar, and cholesterol tests.

Dr. Robert Epsten, gastroenterologist in San Diego, worries about his many patients he said haven't gotten necessary colonoscopies over the last year because, they told him, they can't afford their $250 deductibles or $30 co-pays.

"It takes seven to 10 years for a polyp to become cancerous," he says. "But the problem is that you don't know until you see the patient where they are in that time frame. We like to say, only two things can happen when you don't get a colonoscopy: nothing or something very bad."

And they also are putting off procedures.

"We are seeing patients delay treatment for things like torn rotator cuffs or knee cartilage, because they lost insurance or can't afford to miss work because a spouse was laid off or work is spotty," says Longview, WA, orthopedic surgeon William Turner, MD.

"Paradoxically we also get patients who are pressing to have surgeries that seem premature because their insurance is running out in a few months," he says.

Marc DeHart, MD, an orthopedic surgeon based in Austin, TX, says, "The people we worry about are those rare cases with gnawing, aching pain that is really a tumor, that isn't known without expensive diagnostics." When patients lose their jobs and become uninsured or are strapped for cash, they do defer care, he adds.

"Our elective cases are down 20% to 30%" between the first quarter of 2008 and the first quarter of 2009," DeHart says. "If they had the resources, they might come in sooner, but they may put it off. And this economy makes that problem worse."

DeHart says he hasn't noticed a decline in patients getting hip or knee replacements so far. That may be because those surgeries in general occur in people who are eligible for Medicare, and by the time they come in, they really need those operations.

"When people think of having an operation that big, they're waiting until they're ready and they can't go on much further without having that done," he said. "They wait until they can't walk anymore," DeHart says.

But for those who are cash strapped or uninsured, many stoically soldier on, enduring pain, perhaps engaging in activities less or not at all.

Even if they still have insurance, the economic crisis may mean the money they would have spent on medical or drug co-payments must be used instead for rent or mortgage payments.

Cecil Wilson, an internist in Winter Park, FL, and American Medical Association board member, says it's a fair assumption that in general, people who postpone care will need it more acutely when they finally get it.

"We do know from studies that people who approach Medicare age and know they'll be covered by Medicare, may put off care" until age 65, he says. "There's always a boost in the amount of care they need then."

"We already know that the reason we treat these diseases early—especially high blood pressure and diabetes—is that untreated down the road we see an increased risk of heart attacks and strokes. Interruptions in regular care and treatment do put patients at risk," Wilson says.

"We have the evidence that the sicker people are when they do get care, it's usually in a much more expensive setting like an emergency room, and there's a higher risk of complications down the road. There's a higher risk of dying," Wilson says.

In today's economy, it's becoming apparent that what we consider "health" needs to be redefined, argues Dee Edington, PhD, director of the University of Michigan's Health Management Research Center in Ann Arbor.

In quality terms, the current healthcare model needs to move away from its structure of waiting for defects—and then trying to fix those defects. In other words, the system waits for patients to get sick and then treats them. But this has created a failed healthcare strategy that is posing a major threat to business survival, says Edington, author of a new book, Zero Trends: Health as a Serious Economic Strategy.

"Companies are going out of business because we don't pay attention to healthy people. Our whole country, as we all know, just waits for sickness," he told a Washington audience earlier this month. "Nobody cares about health except for the individuals themselves, and they don't even care because they think, 'It's not going to happen to me.'"

Edington doesn't consider his comments a shot across the bow aimed at healthcare providers. Instead, he sees it as an idea that providers—as employers themselves—can embrace and adopt for their own employee populations. One Michigan healthcare organization, Allegiance Health System, has already taken his suggestions on keeping its employees on the healthier side.

To change the conversation about health in today's environment, Edington proposes five areas of change:

1. Move from health as the absence of disease to health as vitality and energy. Companies can no longer wait for their employees to become sick. Instead, they need to realize that keeping people healthy adds value on both sides: Costs related to disease are lower while productivity increases.
2. Move from caring only for the sick to enabling people to stay healthy. A culture needs to be developed that individuals are "winners" when it comes to health. Some corporate and community cultures are starting to change, and governments have put their stamp on change by legislating smoke-free environments or mandating safety belt laws. But more is needed, Edington says. Employers can help by recognizing and rewarding employees for staying healthy. "Set the incentives for healthy choices. Reinforce every touch point, every e-mail. Every time CEOs have a chance to talk, let them talk about the healthy culture," he says.
3. Move from the cost of healthcare to the total value of health. Governments and organizations generally have focused on how much it costs for someone who is sick. However, the total value of someone's health should be much more than that, he says.
4. Move from individual participation to population engagement. Health promotion or wellness programs have gone down the wrong path, Edington says. "If you try to change a person or provide something where people can change, then where do they go?" he asks. "You can't put a changed person back into the same environment because what happens? They go right back." Instead, shifts need to be made that keep entire populations in mind. Whether it's a company or a government, strategies aimed at entire populations need to be kept in mind that encourage, for instance, compliance with activities such as exercising or smoking cessation.
5. Move from behavior change to a culture of health. All too often, a "blame the victim" mentality has emerged for those who drink too much or do not exercise enough or do not eat healthy foods. The solution was to "sentence" them to behavior change programs, which often fell short of their goals, he says. Instead, more encompassing changes need to take place across the culture through vision and commitment that encourage healthier behaviors.

CMS released its fifth quarterly update of patient satisfaction data late last month, one year after the first Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores from hospitals that participated in the pilot test were made available to the public. This time around, scores from all hospitals that receive reimbursement through the inpatient prospective payment system have been included.

After the first round of the survey was released in March 2008, hospital leaders and staff members were unsure of the extent to which consumers would use the data available. It's since been shown that although some consumers have been looking at the data, they have not been using those data to choose where they receive care.

"I think it created apprehension initially because it was the first time that this type of information would be public," says Deirdre Mylod, PhD, vice president of the acute business division at Press Ganey, a vendor for administering the HCAHPS survey. "I think we've moved from apprehension clearly through to acceptance. Although patients have gone to the site, a fair amount of the research suggests that patients are not using the publicly available data—not just HCAHPS, but any of what's out there—to truly make decisions about their care."

The March release of HCAHPS scores represents survey data collected from patients discharged between July 1, 2007, and June 30, 2008. Although the survey questions have not changed since the initial survey was released, CMS has translated the survey into Chinese, Russian, and Vietnamese for 2009.

In the past 18 months, CMS has also increased its oversight of the guidelines surrounding HCAHPS, specifically about communicating with patients. Hospitals should not communicate with patients about the HCAHPS survey in a way that might affect their responses or diminish their likelihood of completing the survey.

This spring, the Agency for Healthcare Research and Quality (AHRQ) and CMS are collaborating on an HCAHPS chart book, says Carrie Brady, MA, JD, vice president of quality at Planetree, Inc., a nonprofit consulting company that helps hospitals focus on delivering patient-centered care. The book will provide hospitals with national benchmarks for each question that is asked on the HCAHPS survey. This differs from the data available at the Hospital Compare Web site, which show composite scores for each topic covered on the survey. Although hospitals could ask their vendors for benchmarks for each question, having national data offers a more complete picture.

"It'll be nice to have the full set of national data and be able to drill down into individual questions," says Brady. "Your comparative performance compared to a vendor pool, depending on the size of that pool, can tell you a different story than the national data will tell you."

Although the intent of releasing HCAHPS scores and making them available to the public was to give patients more options for choosing their care, the public scores have had a greater effect on the quality of care at hospitals around the country on the whole, says Mylod.

"CMS intended [HCAHPS] to be a public report measure for consumers," she says. "They also hoped it might spur quality improvement because of the fact of transparency. I think that, actually, the second thing has happened more than the first because consumers aren't using it to drive choice, but executives know that how they're doing is public. Clearly, there have been differences in the way people behave."

Press Ganey, a company that works with 42% of U.S. hospitals to help them improve care, analyzed the data coming out of the hospitals with which they consult from January 2007 through July 2008. During that time, large statistical increases were seen in patient satisfaction from the year-over-year data reported in May and June 2008, following the first release of HCAHPS data in March 2008. Press Ganey reported that during the 23 years it has been analyzing these types of data, this jump in patient satisfaction with inpatient care was the largest it had ever seen.

Additionally, CMS ran a large public ad campaign in major national newspapers during May 2008, publicizing the first release of scores. This resulted in a huge spike in visitors to the Hospital Compare Web site. In March 2008, just after the scores were released, about 2 million people visited the Web site. In June 2008, that number jumped to 12 million.

"There were jumps in patient satisfaction scores that clearly said to me that executives were paying attention, boards were paying attention," says Mylod. "The fact of transparency and the public report clearly drove changes in how hospitals behaved."

Brady says the improvements in patient satisfaction that CMS had hoped for are occurring, even if not as many patients as expected are choosing where they receive care based on HCAHPS scores.

"What has been the most compelling effect is that hospitals are more focused on the data," she says.

While more hospitals are making progress in incorporating measures to prevent medical errors, they still have a long way to go to better ensure patient safety using tested methods, according to a new report released yesterday by The Leapfrog Group, the nonprofit organization representing major private and public purchasers of healthcare benefits.

"I guess the big word is going to have to be 'disappointing,'" said Leapfrog CEO Leah Binder. The report, based on 2008 survey results received from 1,282 acute care hospitals nationwide, does show that "hospitals are making great strides and great efforts" to address patient safety concerns, she added.

However, most of the final numbers in Leapfrog's survey "are simply not adequate for the most expensive healthcare system in the world—in what should the best healthcare system in the world," Binder said. Failure to make these changes nationwide means higher mortality rates, higher volumes of care, and higher healthcare costs in the future—factors that could receive closer scrutiny during the healthcare reform debate.

For instance, Leapfrog found from the survey that only 7% of surveyed hospitals fully met its computerized physician order-entry standard (CPOE) standard. Under this measure, hospitals must enter at least 75% of their inpatient medication orders through their CPOE system. They must also assess implementation of the CPOE system with a Leapfrog evaluation tool that ensures the system is alerting prescribers of common medication errors.

The CPOE standard has been in place on the Leapfrog survey since 2002—when only 2% of hospitals met that standard, said Barbara Rudolph, director of Leapfrog's Leaps and Measures.

Research evidence has shown that use of CPOE systems could reduce adverse events by about 88%; if these systems were widely in place nationwide, over 3 million serious medication errors annually could be prevented, Rudolph added.

Also, ongoing research has also shown that nearly 3,000 deaths could be avoided annually if Leapfrog standards were used for eight high-risk procedures performed in hospitals, Rudolph said. "If hospitals were to meet our standards, they could reduce the risk of dying between two to four times."

The rate of reporting hospitals found to be fully meeting volume and risk adjusted mortality standards—or adhering to nationally endorsed process measures—for the high-risk procedures were:

• 43% for heart bypass surgery or coronary artery bypass graft
• 35% for heart angioplasty or percutaneous coronary intervention
• 32% for high risk deliveries
• 23% for pancreatic resection
• 16% for bariatric surgery
• 15% for esophagectomy
• 7% for aortic valve replacement
• 5% for aortic abdominal aneurysm repair

In other findings, the survey showed that only 31% of hospitals fully met the Leapfrog standard for staffing hospital intensive care units managed by board-certified intensivists. However, on a positive note, another 7% of hospitals said they do plan to add intensivists by the end of 2009.

"In the ICU, you can see a reduction of 40% mortality when there is appropriate staffing by trained intensivists," Rudolph said. "Overall, if this were implemented in all urban hospitals with ICUs, we could avoid 54,000 deaths annually, and avoid spending $4.3 billion on the extra care that results when there is not an intensivist in place."

As for hospital infections, 65% of hospitals do not have all of Leapfrog's recommended policies in place to prevent hospital-acquired infections. This rate, though, is an improvement over 2007 in which 87% of hospitals had no policies in place.

Compliance with Leapfrog's efficiency of care standards also was disappointing, Binder said. Under this standard, hospitals must demonstrate high quality care with low resource use. "The vast majority of hospitals couldn't improve their quality using fewer resources than what they do now."

For instance, only 24% met the efficiency standard for heart bypass surgery, 21% for heart angioplasty, 14% for heart attacks, and 14% for pneumonia. "We know . . . there are hospitals that were outstanding in this regard—that had both extremely positive outcomes and at the same time used the fewest resources of any kind," Binder said. "It is possible to do this, so we look forward to seeing great improvement of this in the future."

The Leapfrog Group 2008 Hospital Survey results, along with hospital comparisons, are available at www.leapfrog.org.