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Heartening trends

Significant advances made in cardiac care; Thomson Reuters lists 100 Top heart hospitals


By Jean DerGurahian
Posted: November 16, 2009 - 12:01 am ET
Tags:

Advocate Christ Medical Center knows a few things about heart care.

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The 678-bed Oak Lawn, Ill., hospital participates in the American Heart Association's “Get With the Guidelines” program to track its outcomes in coronary artery disease, stroke and heart failure. The hospital also has created a flow chart to monitor whether heart patients were being readmitted and implemented a discharge blueprint program to ensure coordinated care for patients outside their hospital stay.

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All of this attention has led Advocate Christ to be one of the first to receive an advanced heart failure certification from the Joint Commission, and to find itself on Thomson Reuters' annual list of the top cardiology hospitals for a second year. The last time it was on the list was 10 years ago.

In a country where heart disease has been the major killer for several years, the healthcare industry has increasingly focused on cardiac care. Providers are tackling variations in care with evidence-based processes, improving medical approaches with advanced technology and practices, and measuring mortality outcomes to gauge how patients have fared.

Top-performing hospitals continue to see a drop in inpatient heart attack mortality rates—good news for the whole industry, says Jean Chenoweth, senior vice president of performance improvement and the 100 Top Hospitals program at Thomson Reuters. The research company this week released its list of top cardiology hospitals.

The continued focus on improvement has led providers to make progress in quality of care, but this is only the beginning. Now that the base has been laid, providers will have to study in more detail and with higher levels of sophistication their systems and techniques to continue to improve. “Progress can't be made with low-hanging fruit any longer,” she says.

By utilizing a team-based approach and adhering to guidelines and best practices, providers are able to decrease complications and improve patient outcomes, according to Advocate Christ. “We make sure everyone on the team knows these are the practices,” says Susan Massatt, a registered nurse who is director of critical-care services for the hospital.

Indeed, quality measures seem to have helped put a dent in the number of patients admitted to hospitals because of cardiovascular diseases even as top-performing facilities continue to see a decline in deaths attributable to heart attacks. But as other conditions begin to increase in prevalence, similar guidelines and a similar focus on best practices are not in place to manage them, according to research.

Although hospitalizations increased from 1997 to 2007, hospital stays for coronary artery disease declined by 31% while heart attack admissions fell by 15%, according to research by the federal Agency for Healthcare Research and Quality. At the same time, nonheart-related conditions such as degenerative joint disease and blood infections grew significantly to become the No. 3 and No. 8 reasons for hospitalizations, respectively.

Pneumonia was the No. 1 reason for hospitalizations in 2007, although the number of cases declined by 5% in the 10-year period. Heart attack fell from the No. 4 to the No. 10 spot in the ranking of principal diagnoses for inpatient hospital stays, while chronic obstructive pulmonary disease fell from No. 8 to No. 13 in the ranking.

Hospitalizations for stroke also fell by 14%. The results are part of AHRQ's ongoing Healthcare Cost and Utilization Project, or HCUP, a network of federal, state and hospital databases that track medical practice, quality, outcomes and resources.

The data indicate that quality measures for cardiac care are having a positive effect, says Anne Elixhauser, senior research scientist at the agency. “That's what everyone is hoping for.”

Using heart care as the cornerstone of quality measurement—tools such as Hospital Compare use heart-care measures to score hospital performance—“makes sense” because of the frequency of coronary hospitalizations, Elixhauser says.

Still, the HCUP data are only based on hospitalizations for patients covered by Medicare, which is a limitation for measure development, she says. For example, because treatment for cancer—which the World Health Organization says will surpass heart conditions as the No. 1 killer globally next year—is frequently done in an outpatient setting, data for developing quality measures around that treatment aren't readily available.

What AHRQ would like to do eventually is cull information from all insurance claims including inpatient, outpatient, doctor's offices and clinics for research, Elixhauser says. “I think that's going to be the next frontier of quality measures development.”

Quality measures have played a role in helping to standardize evidence-based practices, but advances in medical care has contributed largely to better heart care as well, providers say.

Cardiology care is becoming more sophisticated, says Mary Anna Sullivan, a physician who is chief quality and safety officer at the 327-bed Lahey Clinic, Burlington, Mass., which has made Thomson Reuters' list of cardiac hospitals eight times, including 2008 and 2009. She cited the quality measure of door-to-balloon time as one of the most important in saving lives. “Where there is good evidence, we have seen improvements.”

Other conditions that might affect heart health, such as obesity and diabetes, are a “much harder nut to crack” when it comes to developing standardized care, Sullivan adds.

Statin drugs to reduce cholesterol and smoking cessation have helped lead to a decrease in heart attacks, says Robert Wilson, cardiovascular executive medical director for the University of Minnesota Physicians. “You can follow heart attack rates” in cities with smoking bans, he says. “It's not totally unexpected.”

Quality measures only look at patients who are in the hospital, but several heart patients who once might have been admitted are now being treated on an outpatient, “observational” basis, as well, he adds. So the bigger quality area to tackle is the number of patients who wind up being readmitted within a month of their stay. “Keeping pretty close tabs on that patient can frequently decrease readmissions.”

Providers are doing a better job of managing lifestyle and risk factors for heart disease, but the systems to manage other, noncardiac conditions that are on the rise are still in their infancy. It has been easy to focus on heart care because of the patient volume and wealth of research available, Wilson says. “From that, we've been able to create those very specific quality systems.”

But having transparent and standardized measures in a system for certain types of conditions will help providers as they begin to apply those systems to other types of conditions.

Measures that are transparent and look at risk-adjusted outcomes are important, says Louis Teichholz, chief of cardiology and medical director of cardiac services for 679-bed Hackensack (N.J.) University Medical Center. The hospital participates in Institute for Healthcare Improvement initiatives to boost care-coordination efforts between hospital and home-care settings. The hospital has made Thomson Reuters' roster seven times, including 2006 through 2009.

What has worked for heart care—transparency, reporting outcomes and following best practices—can work for other conditions. “You build a system that works very carefully, then it's easy to apply a similar system to another condition,” he says.

In addition, standardization has led to greater awareness among patients, especially heart attack patients coming into the emergency department adds Cindy Dougherty, director of quality measurement and improvement at 431-bed Northwest Community Hospital in Arlington Heights, Ill. “I would say the majority of them have already taken their aspirin” before arriving. The hospital has been on Thomson Reuters' list of cardiac hospitals five times, including 2008 and 2009.

Overall, hospitals are prepared to handle any patient condition through better processes, she says. “Once you hard-wire the processes in an organization, it's a thread that goes through regardless of patient population.”

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