Among the hospitals recognized by Truven this year, Morton Plant Hospital, a 687-bed hospital in Clearwater, Fla., has been on the list more than any other hospital—14 times. Using data to improve performance has been central. Kris Hoce, the hospital's president, said the cardiovascular staff implements benchmark performance outcomes on measures such as readmission rates and lengths of stay based on data from the best programs in the country. “We're looking at it constantly, and it is part of the fabric and culture of what we do,” Hoce said.
When the Morton Plant cardiology team noticed early this year that the readmission rate for congestive heart failure patients was in the mid-20s, they looked at how they could improve care transitions to cut that percentage into the teens, said Dr. Mahesh Amin, the hospital's medical director of cardiology. A case manager was hired. That person meets with all heart failure patients before they're released to make sure they have an appointment with a cardiologist within three days of their discharge and have been prescribed the right medications. Since those changes, the readmission rate for heart failure patients has dropped by 10%, he said.
Leaders at Truven's top cardiovascular hospitals say standardizing care enables them to be more cost-effective. “By adhering to guidelines, you should see better quality,” said Dr. Mohamed Hamdan, chief of cardiovascular medicine at the University of Wisconsin. “I don't think that ordering more tests results in better quality. But ordering the right test is better and less costly.”
Before performing a mitral valve repair, U-W cardiologists will evaluate appropriate use criteria and determine how well the patient fits into the guidelines. Protocols like this, along with a focus on transition of care, have caused readmission rates to decline from 13.8% in 2014 to 11% in 2015, Hamdan said. “Medicine has a lot of gray areas, and we're constantly trying to see how we're using techniques and are they always 100% appropriate,” he said.
Hamdan said implementing changes often is challenging and that effective communication is key. “Nobody likes change,” he said. “But when you communicate what the vision is and you listen to what people have to say, they're far more likely to change with you.”
It's important for hospitals to strike the right balance between standardizing and individualizing care, said Dr. Michael Petracek, chairman of cardiac surgery at Vanderbilt University Medical Center in Nashville, which returned to the Truven top 50 list after a five-year absence. “You've got to standardize (care) to some extent,” he said. “But you have to understand that people are not like machines. They don't come standard.”
Petracek said Vanderbilt has implemented protocols for particular conditions such as coronary artery disease that allow physicians to make changes when necessary.
At HonorHealth John C. Lincoln Medical Center, a 266-bed community hospital in Phoenix that made Truven's list for the first time, a high percentage of the patient population is underinsured, with unaffordably high cost- sharing under their health plans, said Dr. Adam Sabbath, the hospital's medical director of cardiology. As a result, physicians and other staff must figure out what drugs and other services patients may need help with after they're discharged.
“Part of the art of discharge and transition of care is making sure people are going home with what they can actually have access to,” Sabbath said.
Treating patients with fewer economic resources poses challenges for both providers and those who measure quality performance. In compiling its top 50 list, Truven currently does not take into account where hospitals are located or the socio-economic composition of their communities, Truven's Young said. So there is no consideration given to social determinants of health or health disparities, which can affect clinical outcomes and make hospitals serving a higher percentage of lower-income patients look worse.
“We think it's likely that patients in certain poorer areas are more likely not to be getting the ambulatory care they need and to come back into the hospital,” Young said. “It is something, particularly with readmissions, we've been looking at.” Truven is currently analyzing ways to incorporate socio-economic conditions into its future reports and studies but has not yet decided on how to address that thorny methodological issue.
Along with John C. Lincoln, four other hospitals are newcomers to the list. Huntsville (Ala.) Hospital and Sacred Heart Hospital in Pensacola, Fla., are teaching hospitals without cardiovascular programs. Saddleback Memorial Medical Center in Laguna Hills, Calif., and Southcoast Hospitals Group in Fall River, Mass., are community hospitals.