Thomas Raya, an interventional cardiologist at United Hospital in St. Paul, Minn., says quality- and process-improvement steps that the 441-bed hospital has taken the past four years helped put the facility on Solucient's list of 100 Top cardiovascular hospitals for the second consecutive year.
R. David Anderson, director of cardiac critical care at 617-bed Sarasota (Fla.) Memorial Hospital, says the collegial atmosphere between cardiologists and heart surgeons developed during the past seven years-along with various process improvements-has enabled the hospital to stay on the list of 100 Top cardiovascular hospitals for four consecutive years.
Dean Kereiakes, medical director of the Heart Center of Greater Cincinnati at 440-bed Christ Hospital, says nearly 80% of the center's open-heart procedures and angioplasties are performed by two surgeons and eight cardiologists. High individual physician volume coupled with a "huge investment" in cardiovascular technology and an experienced nursing staff have helped keep that hospital on the Solucient list for seven consecutive years, he says.
The three facilities, along with 97 others, won a spot on Solucient's seventh annual 100 Top Hospitals: Cardiovascular Benchmarks for Success. The study, released exclusively to Modern Healthcare, evaluates a total of 861 hospitals on seven measures of clinical quality, performance and operational efficiency. Evanston, Ill.-based Solucient uses data from two primary sources: the Medicare Provider Analysis and Review, or MedPAR, data set and Medicare cost reports.
MedPAR is used for patient-level medical record information and charge data. The data contain information on the approximately 12 million Medicare patients who are discharged from the nation's acute-care hospitals annually. Hospitals included in the study in federal fiscal 2003 and 2004 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.
Six of the 100 Top cardiovascular hospitals made the list all seven years, and 23 are first-timers. Of the 100, 30 are teaching hospitals with cardiovascular residency programs, 40 are teaching hospitals without cardiovascular residency programs, and 30 are community hospitals.
"Cardiovascular care is really one of the success stories out there," says Jean Chenoweth, Solucient's senior vice president of performance improvement and 100 Top programs. "All (cardiovascular) hospitals have improved, but these 100 have been reducing medical treatment of AMI (acute myocardial infarction) and increasing use of PCI (percutaneous coronary intervention) and CABG (coronary artery bypass graft surgeries) of heart patients, and death rates have been declining in these hospitals."
One of Solucient's starkest findings is that more than 10,000 additional heart patients would survive each year, or 13.2 per hospital, if all 762 peer group hospitals provided the same quality of care as the 100 Top hospitals, according to Solucient. Another 1,110 patients, or 1.5 per hospital, also could avoid developing such complications as infections and hemorrhaging, according to the report.
During interviews involving five of the 100 Top hospitals, executives and physicians told Modern Healthcare that each hospital uses a slightly different approach toward quality improvement. Still, similarities include having a stable group of surgeons and cardiologists, experienced staff in the catheterization laboratory and operating suite, cutting-edge technology and clinical care, and a multidisciplinary team approach to treatment.
"Performance improvement can be implemented many different ways," Chenoweth says. "What is truly important is that a variety of benchmarks can be used and the medical staff, administration and the board are aligned."
The data show clear differences between 100 Top cardiovascular hospitals-benchmark facilities-and their peers. Key findings include:
Patients stayed fewer days at benchmark hospitals, a 4.53-day average length of stay vs. 5.08 days at peer facilities.
Average adjusted costs per admission were much lower, $11,124 for benchmark organizations vs. $13,048 at peer hospitals.
Survival rates for benchmark hospitals were better by 14.7% for AMI patients; 25.5% for congestive heart failure; and about 22% for both bypass surgery and angioplasty.
Open-heart surgeries were slightly down for all hospitals, but benchmark hospitals averaged 64.4% more than their peers. In 2004, 100 Top hospitals averaged 132 bypass surgeries, down 6% from 140 in 2003. Peer group hospitals averaged 80 bypass surgeries, a 9% decrease from 88 during the prior year.
Angioplasty volume increased at all hospitals, but benchmark hospitals averaged 78% more than their peers. The 100 Top hospitals averaged 410 angioplasties in 2004, a 6.5% increase from 385 in 2003. Peer hospitals averaged 230 angioplasties last year, a 4.5% increase from 2003.
Postoperative hemorrhage and hematoma are on the decline nationally the past five years, but postoperative sepsis has increased significantly. Benchmark hospitals average 0.72 points on Solucient's infection index, a 23.4% improvement over the 0.94 points for peer hospitals. Lower numbers are more favorable. The infection index indicates that benchmark hospitals have 28% fewer infections than Solucient would have predicted. In addition, benchmark hospitals have a hemorrhage index of 0.65 points, a rate that's nearly 20% better than the 0.81 rate at peer hospitals. The hemorrhage index indicates that benchmark hospitals have 35% fewer hemorrhages than Solucient would have predicted.
Lower death rates also were found to be correlated with hospitals that performed more angioplasties (PCIs) and bypass operations (CABGs)-or revascularization procedures-compared with other treatments such as the use of tPA, a clot-busting drug used to prevent heart attacks and strokes. About 71% of AMI patients at the 100 Top hospitals received revascularization compared with 67% for other hospitals.
"One hypothesis is that the 100 Top hospitals tend to adopt technology faster," says Janet Young, a physician and Solucient's senior scientist based in Ann Arbor, Mich. "Another theory is the speed to which patients make it to hospitals. In some states ... patients might not even make it there and so those hospitals' death rates may look better."
Using the data
Sue Penque, a registered nurse and United's vice president of patient care and operations, says the hospital uses national benchmark data, compares it with hospital-specific measurements and works with staff to modify practices. The success over the past four years, she says, has been a testament to teams of physicians, nurses and administrators working together.
"There has been a big effort here to improve mortality rates of congestive heart failure patients to make sure they are offered ACE inhibitors, beta blockers and device therapy (implantable defibrillators). All these things have helped improve our quality," says Raya, a member of St. Paul Heart Clinic, a 33-physician group located across the street from the hospital. The clinic staffs United's John Nasseff Heart Hospital.
Another reason United has improved was the development in 2002 of an acute cardiac network for primary PCI, Raya says.
United's cardiac network works this way: When heart-attack patients arrive at a referring hospital, medical teams make assessments, give patients appropriate medications such as nitroglycerin, heparin, beta blockers and anti-platelet drug therapy, Raya says.
On the other hand, when the patient arrives by helicopter or ambulance at United, the patient is escorted directly to the cardiac catheterization lab, bypassing the emergency room. The goal is to bring the patient from outlying hospitals to United within 90 minutes.
The hospital's ER "door to balloon time" goal is 90 minutes, and the hospital averages 86 minutes, says Julianne Scott, director of the heart hospital. The national average is 156 minutes, according to the Medstate Core Measure Quality Report for 2004, she says.
"We can evaluate patients much more quickly and this has helped us reduce infarction size and early and late morbidity and mortality," Raya says. As a result, he says, United also has been able to reduce patients' length of stay, complications and ultimately costs, he says.
Sarasota Memorial's success at lowering mortality rates has much to do with the skill of physicians and the aftercare of nurses, Anderson says. "There also has been improvement in drug and stent therapy," he says.
While stents-slim, inch-long metal mesh tubes inserted into arteries via a balloon catheter that expand to keep blood flowing-have been used since 1994, the newer drug-eluting stents introduced in 2003 have helped keep arteries open by stopping scar tissue from building up, Anderson says.
Sarasota Memorial also has been able to improve quality the past five years by using integrated electronic medical records, says Gwen MacKenzie, Sarasota Memorial's CEO. "We have less variation in care because of it," she says.
Making Solucient's list for the first time is 565-bed Banner Good Samaritan Medical Center, Phoenix. "We had a real quality program for years, but benchmarking with the (other six) hospitals in the Banner system (in Arizona) has helped us to improve outcomes. ... The numbers changed in six months," says David Cheney, senior administrator of the hospital's 2-year-old Harry J. Cavanagh Cardiology Center.
Quality also began to improve about the same time a small group of 10 cardiologists started performing most of the hospital's 5,800 angioplasties each year, he says. "The outlying hospitals know our outcomes are good, and they know the doctors who perform these procedures," Cheney says. "They are going to get more referrals, and we believe that (volume) is helping us increase quality."
New technology also has been a boon, Cheney says. Four of the six new catheterization labs at the center are equipped with the latest in flat-screen imaging technology that allows for clearer viewing, Cheney says. Two of those labs feature larger flat screens that make it easier for physicians to do peripheral vascular interventions.
St. Patrick Hospital and Health Sciences Center, Missoula, Mont., made the list in 1999 and 2001 in addition to this year. "We are very happy to be back on the list," says hospital President Steve Witz. "What happened (not being on the list for three years) was not a drop in quality. We just did not advance in some areas."
Witz says the hospital has redoubled its efforts to improve operating room infection control procedures. For example, St. Patrick's now limits the number of staff that enters ORs during surgical operations. "We reduced staff turnover during surgery, and this limits the potential to introduce outside infections," he says.
At Cincinnati's Christ Hospital, Deborah Hayes, vice president and chief nursing officer, says involving multidisciplinary teams in the performance-improvement process allows the hospital to stay on top.
Kereiakes, an interventional cardiologist, says the investment in five new radiology labs keeps Christ Hospital on the cutting edge. But Kereiakes says retaining experienced nurses will be difficult because several new open-heart programs have opened. "We don't have certificate of need in Ohio. There are two or three new programs in the planning stages," he says. "Holding on to staff must be assured, but we don't have control over those competing systems when they offer nurses $10,000 bonuses."