The rising tide of quality performance measures, with its early and sustained focus on cardiovascular care, appears to have lifted the performance of all hospitals. Coronary bypass patients are sicker than ever and there are fewer of them, yet more are surviving, according to the latest study by healthcare information and research firm Solucient of its 100 top hospitals in cardiovascular care.View web-exclusive data related to this story.
The encouraging outcomes are true of all hospitals that offer open-heart surgery, although the 100 top heart hospitals have even better results, according to Solucient.
Of the vast array of services that brings patients to hospitals, perhaps no service line has been sliced, diced and analyzed as much as cardiovascular care. The bounty of data that can be captured from procedures such as bypass surgery and angioplasty is feeding the nation's large and growing appetite for quality measures. That could be at least one explanation for the across-the-board improvement in bypass surgery survival rates-the ultimate outcome that provides "one of the clearest pictures of hospital performance," Solucient researchers say.
Although the number of deaths that would be expected from such procedures is increasing, actual death rates are falling. For the 100 top hospitals and their peer group hospitals, patients coming in for bypass surgery are sicker than in recent years, in part because of an increase of patients with shock, pulmonary difficulties after surgery, and respiratory and renal failure, according to Solucient. The results suggest that hospitals and clinicians are doing a better job of "rescuing patients" with complications.
"This is really, really good news for the industry after all the bad news out there," says Jean Chenoweth, senior vice president of performance improvement and 100 Top Programs for Solucient, based in Evanston, Ill. "This is one area where much of healthcare has been focused and performance has been monitored and, in fact, it has made a difference. ... Because this service line is generally considered the most profitable, great scrutiny has been placed on it-no question about that," she says.
The study, released exclusively to Modern Healthcare by Solucient, has for the sixth year identified the nation's hospitals that are setting benchmark levels of performance in a range of cardiovascular services. Only seven of this year's 100 hospitals have the unique distinction of being on the list for six consecutive years.
The list "is trying to identify broad cardiovascular services and provide gross benchmarks for all hospitals to target, and once again the target has moved," Chenoweth says. "But we're also able to say with some pride that we do have some six-year winners."
Avoiding complications, saving lives
If all of the 878 hospitals that were included in the 2004 study group provided the same quality of care as the 100 top hospitals, more than 4,200 additional heart patients would survive each year, according to the Solucient study. Another 1,600 patients could avoid developing complications such as infections and hemorrhaging.
Survival rates are significantly better at the benchmark hospitals, particularly for patients with congestive heart failure and those having bypass surgery or angioplasty. In total, the 100 top hospitals outperformed all other heart hospitals by 9% in survival rates for heart attack; 23% in survival rates for congestive heart failure; and 17% in survival rates for both bypass surgery and angioplasty.
Still, 16% fewer patients died from bypass surgery at the peer group hospitals than would have been statistically expected.
"There's probably a multitude of factors," says David Foster, Solucient's vice president of clinical informatics. "The teams are better; the technology is better; the drugs are better."
This year's study also found strikingly large differences in procedure volume across all criteria. In 2002 and 2003, benchmark heart hospitals performed about twice as many angioplasties and bypass surgeries as their peers, supporting other unrelated studies that found a correlation between volume and outcomes for heart patients.
The study also confirms the observation in recent years at heart hospitals across the country that the volume of bypass surgeries is flattening or decreasing while the volume of angioplasties is soaring. The introduction of drug-eluting stents in the U.S. market in the spring of 2003 is expected to only accelerate that trend (Oct. 21, 2002, p. 4). In 2003, the benchmark hospitals performed on average 166 bypass surgeries, down 11% per hospital from the 187 bypass surgeries performed in 2002. At the peer group hospitals in 2003, on average 88 bypass surgeries were performed, a 3% decrease from the 91 performed during the previous year. Meanwhile, the 100 top cardiovascular hospitals on average performed 436 angioplasties in 2003, a 7% increase from the average 407 angioplasties performed in 2002. The peer group hospitals on average performed 218 angioplasties in 2003, a 9% increase from the 200 performed the previous year.
Patients stayed fewer days at benchmark hospitals (a 4.92-day average length of stay vs. 5.45 days at peer hospitals) at considerably less cost-$10,588 vs. $12,192.
As in the previous years, Solucient's study categorizes the 100 top hospitals into three peer groups: teaching hospitals with cardiovascular residency programs, teaching hospitals without cardiovascular residency programs, and community hospitals. The hospitals were scored on seven measures of clinical quality practices and operation efficiency: volume, medical mortality, surgical mortality, complications, length of stay, cost and percentage of bypass patients in which the internal mammary artery was used. Hospitals included in the study in federal fiscal 2002 and 2003 combined had treated at least 30 patients in each of four categories: heart attack, congestive heart failure, coronary angioplasty and coronary artery bypass graft surgery.
Of the seven hospitals that have appeared on the list of 100 top cardiovascular hospitals for six consecutive years, six hospitals fall into the category of teaching hospitals without cardiovascular residency programs. The other six-time winner is a community hospital. No teaching hospitals with cardiovascular residency programs have appeared on the list all six years. Teaching hospitals without cardiovascular residency programs also provided cardiovascular services at a lower cost-an average $9,863 per case compared with $11,758 per case at teaching hospitals with cardiovascular residency programs and $10,349 per case at community hospitals.
Foster says there is no ready explanation why that group of hospitals performs so well but perhaps as the middle group, teaching hospitals without cardiovascular residency programs have "the optimal balance of resources and a level of severity and complexity." It's an observation Solucient plans to examine further.
Bob Johnson, executive director of Central Minnesota Heart Center at 676-bed St. Cloud (Minn.) Hospital, a six-time winner, says a teaching hospital without a cardiovascular residency program such as his facility's has the best of both worlds. As a tertiary hospital, it offers advanced technology and experienced staff but does not necessarily bear the cost of maintaining a cardiac teaching program.
A team that has worked together a long time in a dedicated heart hospital within a hospital has contributed to St. Cloud's success, he says. "If you think about the quality of a service, you basically want to have fewer providers doing higher volumes. It's not the volume of the organization (that's important,) it's oftentimes the volume of the individual provider," he says.
At 323-bed Munroe Regional Medical Center in Ocala, Fla., obsessive attention to detail and complete standardization in everything its heart program does apparently has differentiated the cardiovascular program. Munroe is the only six-time winner in its peer group of community hospitals. Michael Wesolowski, Munroe's vice president of operations, credits its group practice, the Ocala Heart Institute, which has five sites in Florida, including one across the street from Munroe at 270-bed Ocala Regional Medical Center. Ocala Regional has been on the 100 top heart hospitals list five years.
The Ocala heart group will perform 750 open-heart surgeries, 3,200 cardiac catheterizations, and 1,600 angioplasties at Munroe alone this year, Wesolowski says. Bypass surgeries are down about 10%, but that might be attributable to the opening of a competing heart program at 171-bed Citrus Memorial Hospital in Inverness, Fla., he says. True to form, Munroe is conducting "a detailed study" to determine what is causing the erosion in profit margin. It's crucial to the financial health of the hospital, which this year will post about a 2% profit margin equal to a little more than $500,000.
"If there weren't a cardiovascular program, I don't think there would be a margin. It's the primary business we're in," Wesolowski says.
Munroe's clinicians similarly are treating tougher cases than ever in its open-heart surgery program, says Carol Floyd, director of cardiovascular services at the hospital.
That hasn't compromised outcomes "probably because we're getting patients in the cath lab table within two hours or an hour when they come in the door," she says. "It's the maturity of the program. The more you do, the better you are."
The speedy times have allowed the hospital to nearly stop using clot-busting drugs to treat heart attacks in favor of emergency angioplasty, which recent studies have suggested has better outcomes (Jan. 12, p. 28). The hospital also has "probably some of the shortest pump runs in the country," meaning surgery patients are on the heart-lung machine a minimal amount of time, which in theory reduces complications.
Meanwhile, at 459-bed Scott and White Memorial Hospital in Temple, Texas, separating the business side of cardiovascular care from the clinical side has served the facility well, says Gregory Dehmer, director of the division of cardiology and professor of medicine at Texas A&M College of Medicine. The teaching hospital, which has a cardiovascular residency program of 16 fellows, has been on the Solucient 100 top heart hospitals list for the past five years. "We have obviously a very talented and dedicated group of physicians but also an excellent support structure that allows the doctors to be just that and focus on making patient care as best as possible," he says.
In line with national trends, Dehmer says bypass surgeries at Scott and White are leveling off with the advances in stent technology while at the same time the patients who are being referred to heart surgeons are those who have already had one bypass surgery if not two or three. To the credit of the surgeons, mortality outcomes have been maintained in spite of the higher-risk group of patients, he adds. More complicated cases indeed may be one reason why death rates continue to decline.
"The more I worry upfront, the better the patient winds up. So it may just be greater awareness on the part of our surgeons," Dehmer says. "Not to imply they wouldn't always be thoughtful, but I think you always take that extra deep breath before."View web-exclusive data related to this story.