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Providence St. Patrick Hospital, Missoula, Mont.
Providence St. Patrick Hospital, pictured here, launched the International Heart Institute of Montana in 1995.

Web-exclusive: Among the best at heart

Continuous improvement helps organizations make Truven Health's annual list of the 50 Top Cardiovascular Hospitals

By Linda Wilson
Posted: September 29, 2012 - 12:01 am ET

Located in rural western Montana, in a valley of the Rocky Mountains known more for fly fishing than medicine, sits the unexpected: a top cardiovascular hospital.

Providence St. Patrick Hospital in Missoula launched the International Heart Institute of Montana in 1995 when officials there recruited Dr. Carlos Duran, the Spanish-born cardiac surgeon, Ph.D.-trained scientist, and inventor of the Duran Ring, which is used in mitral-valve surgeries.

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Though the community hospital had a cardiovascular program in place before Duran's arrival, he took it to a higher level, combining leading-edge surgery and cardiology with basic-science, translational and clinical-trial research through a partnership with the University of Montana. Duran and associates have earned U.S. and international patents as a result of their research.

Duran has since retired, but the institute continues to thrive. The cardiovascular surgeons and cardiologists work with nurses, pharmacists, quality-improvement experts and other hospital employees to continually refine performance on clinical outcomes. The hospital employs the physicians in a group practice, which facilitates collaboration because they are not competing with each other for patients, according to Joyce Dombrouski, chief acute services officer at Providence St. Patrick.

As a result of these efforts, St. Patrick landed on Truven Health Analytics' 14th annual list of hospitals that make up the Truven Health 50 Top Cardiovascular Hospitals, 2013. Truven—formerly the healthcare business at Thomson Reuters—ranks heart programs based on an analysis of quality, safety, and efficiency metrics using data from Medicare cost reports, Medicare Provider Analysis and Review, or MedPAR, and Hospital Compare. This is the sixth time Providence St. Patrick has been on the list.

UC San Diego Medical Center, which landed on Truven Health's list of top heart hospitals for the first time this year, also has made a substantial investment in its heart program. It opened the $138 million, 54-bed UC San Diego Sulpizio Cardiovascular Center in 2011 on the campus of Thorton Hospital in La Jolla. (The project was a 2012 Modern Healthcare design award winner.)

A total of 54 physicians—including cardiac surgeons, cardiologists, pulmonologists and radiologists—are based at the center, which houses inpatient and outpatient heart and stroke services. The cardiovascular center's physicians also care for patients admitted to the Hillcrest location in San Diego, which is 12 miles away but under the same Medicare license.

The size of the staff allows individual physicians to be very specialized, which helps drive good outcomes such as low complication rates, says Dr. Ehtisham Mahmud, co-director of Sulpizio Cardiovascular Center and chief of cardiovascular medicine.

For example, the four electrophysiologists on staff are the only doctors who implant pacemakers in patients, while the four interventional cardiologists are the only physicians who put in coronary stents, Mahmud says.

“The physicians are very subspecialized. We have high volume, experienced operators,” Mahmud says. The staffs that work with the physicians, such as nurses and technicians, also are highly skilled specialists, he says.

UC San Diego and St. Patrick are examples of the type of focus on clinical outcomes that is necessary to land on the list of 50 Top Cardiovascular Hospitals.

To be named to the list of the top cardiac hospitals, or benchmark institutions, 1,004 hospitals were compared with others within the same category: teaching hospitals with cardiovascular residency programs (218 hospitals), teaching hospitals without cardiovascular residency programs (274 hospitals) and community hospitals (512 hospitals).

Hospitals were scored on 22 measures of quality, efficiency and safety for acute myocardial infarction, (AMI) congestive heart failure, coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI).

Top hospitals out-performed peer hospitals on all measures, but some of the largest percentage differences were in risk-adjusted mortality and complication rates.

Top hospitals' median, risk-adjusted mortality score was 12.2% lower than benchmark hospitals for AMI, 18.4% lower for heart failure, 35.2% lower for CABG and 24.2% lower for PCI.

Similarly, top hospitals' median, risk adjusted complications score was 18.3% lower than benchmark hospitals for AMI, 35.1% lower for heart failure, 4.9% lower for CABG, and 11% lower for PCI.

The CMS data used in Truven Health Analytics' database includes information about whether a complication for an individual patient was present on admission, so the results of the study are not skewed by those cases.

“There is a big difference between the winners and the nonwinners. Those differences in complications are not a result of pre-existing complications, so it sharpens the differences between the benchmark hospitals and the peer group,” says Jean Chenoweth, Truven's senior vice president of performance improvement and 100 Top Hospitals. “That helps identify hospitals that really have different practices.”

Dr. Harvey Waxman, chief of cardiology at Penn Presbyterian in Philadelphia, says his organization adheres to a program focusing on continuous improvement to reduce surgical complications.
Dr. Harvey Waxman, chief of cardiology at Penn Presbyterian in Philadelphia, says his organization adheres to a program focusing on continuous improvement to reduce surgical complications.
At Penn Presbyterian Medical Center in Philadelphia, which has been on the list seven times, including this year, the staff adheres to a process of continuous improvement to reduce surgical complications, according to Dr. Harvey Waxman, chief of cardiology at Penn Presbyterian.

For nearly a decade, the staff has been continually refining processes to reduce wound infection rates in heart surgery patients. Even though the rate has been below 1% for the past several years, the staff wants to do better.

“Our goal is zero percent,” Waxman says.

The most recent change was a protocol in which patients are instructed to use a special antibiotic nasal cream at home prior to their surgery. The cream is designed to eliminate staphylococcus aureus bacteria that colonize in the nose. Patients with the bacteria in their nose have a higher risk of developing a wound infection, Waxman says.

“You can never let up,” he says. “You get one infection and you go back and look and figure out what happened. It is a never-ending process.”

Dr. Joseph Knapp, a cardiologist at St. Patrick, agrees. Although the hospital's heart-failure readmissions are among the lowest in the country, according to Knapp, the staff continues to refine its patient-care processes. For example, St. Patrick is now evaluating a proposal to develop a heart-failure clinic in which physical therapists, dieticians, social workers and other nonphysicians would help patients address lifestyle issues, such as sedentary behavior and poor food choices.

Heart-failure patients “are seen by a primary-care physician (already), who focuses on medication management, but there is an awful lot in the management of these people with chronic conditions that is not so much pharmacy-specific as it is lifestyle specific,” Knapp says.

Linda Wilson, a former Modern Healthcare reporter, is a freelance writer in McHenry, Ill. Reach her at

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