Heart-healthy

Gregory Dehmer, a physician who’s director of cardiology at 517-bed Scott and White Memorial Hospital in Temple, Texas, attributes a committed team, cutting-edge technology and quality-improvement efforts with helping his facility make Solucient’s 100 top cardiovascular hospitals list for seven consecutive years.

Colleen Nadeau, a registered nurse who is director of cardiology and critical care at

258-bed St. Joseph’s Hospital, St. Paul, Minn., points to a dedicated staff, benchmarking and a rapid quality-improvement program as critical to improving quality and keeping the hospital on the list for two straight years.

Donna Disbro, also a registered nurse and vice president for cardiovascular services at 298-bed Blake Medical Center, Bradenton, Fla., credits a multidisciplinary team approach, a motivated staff and attention to detail with propelling the hospital onto the list for the first time.

The three hospitals are on Solucient’s eighth annual 100 Top Hospitals: Cardiovascular Benchmarks for Success. The study, which was released exclusively to Modern Healthcare, evaluates 844 hospitals on eight measures of clinical quality, performance and operational efficiency.

Solucient, based in Evanston, Ill., uses data from two primary sources: the Medicare Provider Analysis and Review, or MedPAR, data set, and Medicare cost reports from 2004 and 2005. MedPAR is used for patient-level medical record information and charge data. The data contain information on 12 million Medicare patients who are discharged annually from the nation’s acute-care hospitals.

Four of the 100 top hospitals made the Solucient list all eight years, six have been on the list for seven years and 29 facilities are on for the first time.“The quality of cardiac care has risen significantly in this country,” says Jean Chenoweth, Solucient’s senior vice president of performance improvement and 100 Top programs. “The data show there is a difference in performance between the winners and the nonwinners. This shows there is still room for improvement.”

One of Solucient’s starkest findings is that more than 8,390 additional heart patients would have survived in 2005, or 11.3 per hospital, if all 744 peer-group hospitals provided the same quality of care as the 100 top hospitals—or benchmark facilities—according to Solucient.

Another 574 patients, or roughly 0.8 per hospital, also could have avoided developing complications such as infections and hemorrhaging, according to the latest study.

Dehmer: It's the team that saves lives, not just the technology.

By emphasizing quality improvement during the past eight years, hospitals have saved thousands of lives, Chenoweth says.

“Cardiovascular-care trends suggest deaths from cardiovascular disease have declined because of the new technologies available, the speed at which hospitals adopt new technologies, and the drugs available to control and reduce the impact of congestive heart failure and other heart diseases,” she says.

The data show clear differences between the 100 top hospitals and their peers. Noteworthy findings include:

Patients stayed 10% fewer days at benchmark hospitals, a 4.5-day average length of stay vs. five days at peer hospitals.

Average costs per case were 12.5% lower for the 100 top hospitals—$11,566 for the benchmark hospitals vs. $13,218 for peer facilities.

Survival rates at benchmark hospitals were better by 13.9% for acute myocardial infarction, or AMI, patients; 11.1% better for congestive heart failure, or CHF; 20.2% better for bypass surgery; and 14.4% better for angioplasty.

Open-heart surgery volume was down for all hospitals, but benchmark hospitals averaged 45% more surgeries than the peer hospitals. In 2005, the 100 top hospitals averaged 111 bypass surgeries, down 11.9% from 126 in 2004. Peer group hospitals averaged 76 bypass surgeries, a 7.3% decrease from 82 the previous year.

Angioplasty volume also decreased at all hospitals, but benchmark hospitals averaged 69.2% more procedures than the peer group. The 100 top hospitals averaged 388 angioplasties in 2005, an 8.3% decrease from 423 in 2004, while peer hospitals averaged 229 angioplasties, a 2.1% decrease from 234 over the same time period.

Postoperative complications have been on the decline nationally. Benchmark hospitals have an average infection index of 0.74 compared with 0.87 for peer hospitals, a 14.9% difference. Lower values are more favorable. The reference value for this index is 1. Therefore, a 0.74 indicates 26% fewer events than expected. In addition, benchmark hospitals have a hemorrhage index of 0.69 vs. 0.96 at peer hospitals, or 28.1% better.

For 2006, Solucient added an eighth measurement: a core measures score based on the Joint Commission on Accreditation of Healthcare Organizations’ Oryx outcomes initiative, which began in 2002. The program covers five areas: AMI, CHF, pneumonia, pregnancy and related conditions, and surgical infection prevention.

Nadeau: Key to gains was communication between providers.

However, Solucient’s core-measures score is based on the AMI and CHF data only.

The 100 top heart hospitals’ core measures score for AMI was 95.2% compared with 92.8% for the peer group, a 2.4 percentage point difference. For CHF core measures, top heart hospitals scored an average median of 90% compared with 87% for peer hospitals, a 3 percentage point difference.

“What (the core measures) reflect is attention to basic care and following national benchmarks,” Chenoweth says.

The AMI core measures include giving patients angiotensin-converting enzyme, or ACE, inhibitors or angiotensin II receptor blockers, or ARB; for CHF patients, giving aspirin at arrival and discharge, giving beta blockers at arrival and discharge and giving percutaneous coronary intervention within 120 minutes of arrival. The two CHF core measures are giving patients ACE inhibitors or ARB and assessing CHF patients.

“The data show all hospitals have taken (action to improve) performance on JCAHO’s core measures, but there is still room for these hospitals to improve,” Chenoweth says. The 100 top cardiac hospitals “have found a way to perform better than (their) peers.”

Hospital officials interviewed by Modern Healthcare say each facility closely follows recommended quality-improvement and best-practice recommendations along with benchmarking key measurements. They also report a fairly stable group of surgeons and cardiologists, an experienced catheterization laboratory and operating room nursing staff, as well as advanced technology.

At Scott and White—one of the 30 teaching hospitals on Solucient’s roster with a cardiovascular residency program—Dehmer says the hospital participates in a number of national heart registries and uses the benchmark data to compare with hospital-specific measurements.

“You can have the best equipment and technology, but a great (catheterization) lab doesn’t save the life; it is the team,” Dehmer says. “It is the people and their commitment to strive to be the very best that makes the difference.”

Dehmer says the hospital’s 5-year-old electronic medical-record system has helped staff improve quality.

“Our EMR system has been extremely helpful,” Dehmer says. “You can make notes and ensure all core measures are completed.”

Scott and White is an independent, not-for-profit teaching hospital that is clinically affiliated with Texas A&M University System Health Science Center College of Medicine, College Station, Texas.

At St. Joseph’s, one of 40 teaching hospitals on the list without a cardiovascular residency program, Nadeau says exceeding national benchmarks and conducting rapid cycle improvements help staff improve outcomes. St. Joseph’s is part of four-hospital, not-for-profit HealthEast Care System, based in St. Paul, Minn.

For example, in 2005 Nadeau’s team noticed its contrast-induced nephropathy, or CIN, rate—acute kidney failure occurring within 48 hours of exposure to intravascular radiographic contrast material not attributable to other

causes—for coronary angiograms in bypass patients was 13.6%, a figure far greater than the 7.8% the hospital wanted. CIN is the third most common cause of hospital-acquired renal failure, leading to higher mortality rates, longer hospital stays and poorer outcomes.

Through a CIN renal treatment protocol that identified high-risk patients, the hospital was able to reduce CIN rates to 5.25% during the first six months, Nadeau says.

“Cardiologists and surgeons wrestled with this for some time,” she says. “It bothered me that (CIN) was high. … Patients need to be seen preoperatively in the clinics, where the protocols are started, and then communication needs to be transferred to the hospital. It was hard to educate the clinics, which is why not a lot of hospitals do this.”

While St. Joseph’s goal is to hit 100% of the JCAHO’s core measures, Nadeau says the hospital is at 96%. “The closer you get to 100%, the more diligence and focus you need for these patients,” she says. To help close the gap, Nadeau says the hospital hired an advanced practice nurse last year to review charts and ensure core measures are met.

Blake Medical Center credits teamwork for its appearance on Solucient's list.

Meanwhile, at Blake Medical, one of the 30 community hospitals on Solucient’s list, Disbro says implementing a blood-sugar-control program three years ago aimed at diabetic patients going into surgery has helped reduce infections, mortality rates and lengths of stay. Studies have shown that patients with high glucose levels before surgery have higher mortality rates because they are more susceptible to postoperative infections.

Blake Memorial also has implemented hospitalwide rapid response teams, created standing orders for patients with heart problems and instituted procedures to follow JCAHO’s core measures, Disbro says. Blake is part of 172-hospital HCA, Nashville, the nation’s largest investor-owned hospital chain.

“One key component that sets Blake apart is that we have developed a multidisciplinary (heart) team that fosters communication and interdependence,” Disbro says. Created seven years ago, the team—which includes cardiologists, cardiovascular surgeons, emergency physicians and staff members in nursing, respiratory care and laboratory—meets once a month to review best practices.

“There have been some barriers along the way, but for the most part we have been very fortunate to get physician participation as well as the staff,” Disbro says. “The most difficult challenge is we have so many patients and so many staff, sometimes patients slip through the cracks. When this happens, we hone in on that, drill down, find out where we are falling short and make changes.”

Jay Greene is a former Modern Healthcare reporter and now a freelance healthcare writer based in St. Paul, Minn. Contact Greene at jaywriter@comcast.net.