The ranks of the 160,000 Americans killed by stroke each year could be reduced by as many as 5,000 if all hospitals performed at the level of benchmark institutions, according to Solucient's 100 Top Hospitals: Stroke Benchmarks for Success.
The first-time study, conducted with the assistance of NeuroSource, a neuroscience consulting and practice development company, also determined that benchmark hospitals, despite treating sicker patients, have lower costs, shorter lengths of stay, and still manage to achieve better clinical outcomes. In fact, in all six performance measures examined by Solucient, including mortality and complications, 100 Top Hospitals exceed their peers.
With a reported 600,000 people who suffer a new or recurrent stroke every year, strokes represent a specialty area that meets Solucient's service line program criteria of high risk for patients, high volume for hospitals and high cost to payers. Hospitals that made the top 100 list treated twice as many stroke patients as their peers, according to the study.
As with Solucient's other service line analyses, comparison of like hospitals was a priority for determining the stroke benchmarks. Because teaching and residency programs have a significant effect on a hospital's scope of services, as well as the type of patients it treats, Solucient assigned each hospital to one of three peer groups: teaching hospitals with neurology residency programs; teaching hospitals without neurology residencies; and nonteaching community hospitals.
Four years ago, in a collaboration with local stroke care providers, St. John's Hospital in Springfield, Ill., developed a stroke center that would standardize care from the first minute a stroke patient entered the emergency department. But it took a full two years before St. John's began to see solid improvement in the way patients were cared for, says Mark Gerberding, director of rehabilitation services.
"These things have taken an evolutionary status in how we improve care," Gerberding says. "It's not a one-time decision. The way we look at this designation is like frosting on the cake."
With 735 beds, St. John's, which also made the 100 Top list of orthopedic benchmarks, is the largest of 13 institutions sponsored by Hospitals Sisters Health System. Gerberding says with its standardized care initiative, the hospital has been able to manage stroke more aggressively, resulting in shorter lengths of stay.
That is reflective of the study's findings for St. John's fellow hospitals with neurology residency programs, whose 4.8-day, severity-adjusted average length of stay was more than 14% lower than peer hospitals, where stroke patients remained in the hospital for an average of 5.6 days. Benchmark hospitals in this category also averaged wage- and severity-adjusted costs nearly $300 lower per admission.
Another benchmark stroke hospital named in Solucient's study, 100-bed Englewood (Fla.) Community Hospital, believes it earned its place on the list because of its substantial experience identifying and treating stroke patients.
"We have a large retirement and elderly population, and due to that we've picked up a lot of experience treating strokes," said Robert Sohl,
an emergency room charge nurse at Englewood Community. "Three-quarters of our nurses have been here five years or longer. They can pick out strokes quickly and can start treatment fast."
Sohl also attributed Englewood Community's success to a staff that is well educated about strokes and the effectiveness of preventive measures such as reducing blood pressure for at-risk patients and getting stroke victims into rehabilitation quickly to minimize
long-term damage and prevent additional strokes.
Englewood's fellow community hospital winners had the lowest mortality index of the three comparison groups, outperforming their peers by 36%. These facilities also achieved the greatest percentage in their ability to discharge their stroke patients directly home, as opposed to a nursing or rehabilitation center.
Salinas Valley Memorial Hospital in Salinas, Calif., is located in the heart of an area known as the salad bowl of the world, a community with a rich agricultural heritage on California's Central Coast. Despite the misperception some might have of this region as a backwoods rural outpost, Salinas Valley Memorial prides itself in providing cutting-edge care with state-of-the-art technology.
Having been recognized by Solucient in previous years as a top 100 cardiovascular hospital, officials at 230-bed Salinas Valley Memorial credit their physicians in each department for setting high expectations, passing along knowledge, and creating a team atmosphere that is open to
"It's a whole team that is really in tune with the latest in technology as well as the latest in evidence based medicine," says David Perrott, M.D., medical director and assistant administrator.
In addition to the physicians' technical judgment and skills, Perrott recognizes the important role of the diagnostic imaging department in quickly evaluating stroke patients and the superior monitoring systems the hospital has put in place to notice any neurological changes that occur.
"When dealing with a stroke patient, you have to be prepared for almost every type of situation," Perrott says. "We are able to handle all the patients, from small to major stroke -- rarely do we have to send a patient elsewhere."
Chief executive officer Sam Downing says part of the hospital's strength and stability comes from the support of its five-member board, elected from within the hospital district. "The board has adopted the same clear message on the importance of quality," Downing says.
Additionally, Salinas Valley Memorial has committed to staying competitive, Downing says, as evidenced by salaries that match those paid in the San Francisco Bay area, where the cost of living is notoriously high.
"As a debt-free hospital, we don't have to pay capital and interest payments, so we are able to continually invest," Downing says, and that includes investment in people.
One area not addressed in the study, perhaps due to the difficulty of measuring it objectively, is a hospital's attempt to educate its community about how to prevent the risk of stroke. Yet it may be indicative of the drive for excellence behind some of the top performers.
South Carolina has led the nation in stroke mortality, says Tim Carter, M.D., associate professor of neurology at the Medical University of South Carolina in Charleston, one of the winning teaching hospitals with a neurology residency program.
"Stroke is a common problem that takes its toll on the folks who live here," Carter says. "There is a large move within our university focused on preventive efforts in terms of all types of vascular disease. You get a lot more bang for your buck than dealing with them as an acute problem when the stroke happens. ThatOs not necessarily recognized in typical measures."
If a problem does become severe, Carter says Medical University is prepared, with bits and pieces of stroke pathways it has used in the past having taken hold to become part of an embedded stroke-care culture.
"When someone shows up in the emergency room, the acute stroke response team is familiar with the types of things that need to happen with those patients as they progress through their hospital stay," Carter says.
Data for Solucient's stroke study were taken from publicly available Medicare Provider Analysis and Review (MedPAR) information and from the company-s DRG and hospital databases. Each of the hospitals in the study treated at least 50 patients for ischemic stroke--characterized by narrowed arteries that cut blood flow to the brain--in both 1998 and 1999.
The top 100 stroke hospitals represent 33 states--Florida was the champion with 21 hospitals on the list. Michigan, Pennsylvania, New York and Texas also fared well with 31 hospitals on the list among them.
Modern Healthcare reporter Jeff Tieman contributed to this story.