At the heart of quality

At a time when the term “Choosing Wisely” is an understood shorthand in quality and patient-safety circles, and the movement to curb the use of unnecessary medical tests and procedures is quickly gathering momentum, Truven Health Analytics is taking note.

For the latest version of its annual Cardiovascular Benchmarks for Success study, listing the 50 top-performing hospitals when it comes to cardiac care, the Ann Arbor, Mich.-based research firm quietly added two new metrics of appropriate use to its existing set of performance measures.

The first one, available on the CMS' Hospital Compare website, measures the use of cardiac imaging for preoperative risk assessment in patients undergoing noncardiac low-risk surgery, such as endoscopy.

Such imaging is widely considered to be unnecessary, as well as a major driver of ballooning medical costs, said Janet Young, a lead scientist at Truven and the principal investigator of the Cardiovascular Benchmarks report.

Indeed, the American College of Cardiology cautioned against routine cardiac imaging for noncardiac low-risk surgeries as part of its contribution to Choosing Wisely.

Led by the Washington-based ABIM Foundation, affiliated with the American Board of Internal Medicine, Choosing Wisely partners with medical societies, each of which contributes a list of five commonly ordered but usually unnecessary—and sometimes harmful—tests and procedures, based on available evidence. The ACC was among the first nine medical societies to release top-five lists when the initiative launched in April 2012.

“We aligned ourselves with Choosing Wisely because it addressed how you explain to patients that sometimes less is more,” said Dr. William Zoghbi, the ACC's immediate past president.

As of last week, the number of medical societies participating in the initiative has grown to 58.

Truven's second new measure, Young said, looks at hospitals' use of bilateral cardiac catheterization in patients with coronary artery disease.

Most patients with coronary artery disease need only left-sided cardiac catheterization unless they have some other additional conditions, Young said, adding that bilateral cardiac catheterizations are more costly and introduce additional risks, such as infection.

“As we continue to try to differentiate hospitals, we're looking to expand what we're able to measure,” she said. “These metrics go beyond the areas that we have looked at before.”

Truven gathered data on the two new measures for this latest report but did not use them in determining this year's 50 top cardiovascular hospitals, said Jean Chenoweth, senior vice president of performance improvement at Truven. They will be included next year, she predicted, barring any legitimate concerns from hospitals.

“The trend for care is moving toward balancing cost and quality, and we need to be measuring along those lines,” Chenoweth said. “We're changing our methodology, but we want to give people in the field time to provide feedback.”

Now in its 15th year, Truven's list of top cardiovascular hospitals recognizes 50 high-performing hospitals from a field of more than 1,000, based on performance across measures of cardiovascular safety, quality and efficiency, including mortality, 30-day readmission rates and whether hospitals followed evidence-based practices, such as providing instructions at discharge (See chart, p. 22).

Truven released its 50 Top Cardiovascular Hospitals list exclusively to Modern Healthcare.

Scott & White Memorial Hospital, a 554-bed facility in Temple, Texas, appeared on Truven's list of the 50 top cardiac hospitals for the 11th time this year. Dr. Gregory Dehmer, director of the cardiology division for Dallas-based Baylor Scott and White Health—Baylor Health Care System and Scott & White Healthcare completed a merger in September, forming the largest not-for-profit system in Texas—said there is no “magic potion” that explains the hospital's consistently high performance.

Instead, he credited Scott & White's repeated appearances on Truven's list to numerous factors, including physician integration and use of actionable quality metrics, such as door-to-balloon time for heart attack patients.

The addition of measures for misuse and overuse of procedures mirrors the work that has been done for years by the ACC as part of its “appropriate-use criteria,” Dehmer said. Those criteria list various treatment scenarios in areas such as imaging, diagnostic catheterization and coronary revascularization. Within each scenario, the criteria classify interventions as “appropriate,” “may be appropriate” and “rarely appropriate.”

For instance, the appropriate-use criteria deem echocardiography to be rarely appropriate for re-evaluating patients who were shown in a prior echocardiogram not to have heart valve disease and who have since had no change in clinical status.

“The (appropriate-use criteria) are meant, first and foremost, to be a yardstick to study some of the variation in cost and quality across the U.S.,” said Dehmer, who helped draft the criteria. “It's something that needs to be done and I'm glad that Truven has started to move in that direction.”

Dr. Joseph Knapp, a cardiologist at 134-bed Providence St. Patrick Hospital, Missoula, Mont., agreed that cardiology and cardiovascular surgery have been ahead of many other specialties when it comes to appropriate use. “We've been front and center on this issue for some time now,” he said.

Cost and value are especially pressing issues in Montana, a state that ranks near the bottom for economic vitality, Knapp said. “We are a low-income state and we have to be very cognizant of that.”

Providence St. Patrick made its seventh appearance on Truven's list this year, which Knapp credits largely to the hospital's careful and collaborative approach to cardiac care. Providence St. Patrick's cardiologists and cardiovascular surgeons work alongside one another in the hospital's International Heart Institute, which was formed in 1995.

Knapp said the institute's clinicians meet three times a week to discuss cases and appropriate treatments. At a recent meeting, for instance, there were seven cardiologists and two surgeons in the room. “Patients come in with a complex problem and they get a complex evaluation,” he said.

Follow Maureen McKinney on Twitter: @MHMMcKinney