It’s an amazing statistic: in just ten years, the US heart attack rate has been reduced by 38%, as reported in a wonderful and hightly suggestive article in the June 21, NYT, here.
Perhaps most hopefully, in this week of renewed attention to matters of race and poverty, disparities that used to exist in times to treatment with respect to age, poverty, and race have disappeared.
There are many reasons, but one of the most signficant, and the one that I will analyze today, are focused attention to, and changes in the reasons that there is such a long time between arrival at the hospital, and the treatment to push through the blockage.
The story really begins, significantly, with the fact that Medicare had long been collecting data on that length of time for each hospital. (I do not need to point out the reaction to any suggestion that equivalent data be collected about legal aid.)
What that data made possible was a study, conducted by Yale University Hospital, which showed that”
[i]t was a bell curve year after year, and the times were not getting any better. But there wire a few hospitals at the tail end of the curve that year after year were treating people in an hour or so.
Dr. Krumholz and his colleagues visited the 11 best performing hospitals. They were not famous institutions or major medical centers, said Elizabeth Bradley, a professor of public health at Yale and a leader in the project. Some were community hospitals; others were far from major population centers. The investigators recorded every detail of how the hospitals got things done and ended up with a short list of what the stellar performers had in common . . .
The procedures identified by the researchers included things such as transmitting the EKG from the ambulance, allowing the ER doctor to make a decision to go for a procedure without consulting others, having the whole team called in quickly from nearby, with a single call, even before the patient arrived, and, continuous monitoring of outcomes. (Most of these might seem obvious to us, but they were far from universally used.)
Then it gets really interesting.
Dr. Krumholz and his colleagues persuaded The New England Journal of Medicine to publish their already accepted paper in the same week at the end of November 2006 that the American College of Cardiology announced a national campaign to get hospitals to change their ways. Twelve hundred committed to doing so.
The challenge had specific targets, to get the blood flowing for half of patients within 90 minutes of arriving at the hospital. (To some of us that might seem un-ambitious.) “Now, nearly all hospitals treat at least half their patients in 61 minutes or less, according to the most recent data from the American College of Cardiology.”
The campaign (for that is what it was) had immediate results: “Doctors and hospitals began competing to see who could have the best times. The initiative tapped into professional pride and a thirst to be the best. And, of course, hospitals wanted patients.”
End of story? Not quite. And there is an important lesson in how to think about data in the next chapter. The research started to show that while times were being reduced, overall outcomes were not. Is this an argument against the theory and the campaign. No, because what was happening was that word was out, the culture was changing, and sicker people were now having the procedure. So the impact on the original treatment population was indeed still positive. It is easy to imagine that, similarly,for example, improvements in assistance to eviction defendants could result in reduced default rates, and increased post substantive hearing eviction rates.
The article concludes with a discussion of how hospitals continue, case by case, to review why times were not shorter, and what could have been done (and would be done in the future) to reduce times.
There are so many lessons here for the legal system, and here are just a few of them. Of course medical outcomes are often easier to measure, and of course there is agreement rather than disagreement about what is good or bad, but overall the lessons are waiting to be applied.
1. Setting public, concrete, measurable, and achievable goals is critical. In the legal context they will vary by type of institution, but that’s no reason not to analse them. Courts should have all litigants given sufficient information to understand their rights and how to protect them, as well as understanding the court’s orders. Advocacy legal aid programs should have goals for percentages of those given full triage, and how quickly, those given full information, and specific outcomes by case type.
2. Such goals should whenever possible be within the control of a single institution. The medical system did not use as its measure time from 911 call, or time from pain, but time from arrival. So “just outcome” is a hard one, but “everyone fully heard with case decided on facts and law,” is, at least theoretically, doable
3. We desperately need nationally comparable outcome measures, and the centralized reporting that gives them utility.
4. Competition is critical. In a monopoly system, there is almost none. No wonder the pressure to adopt innovations is so low. It is a little scary that much of the openness to court reform has come from the argument that private sector players are moving to private courts.
5. Outcome data needs to be read carefully. Successful programs almost always produce unanticipated consequences. And, unless fully understood, those may undercut the clarity of the success, but not the fact of the success.
P.S. For follow up plans for this heart research, see here.