Honing heart care: Truven's top 50 cardiovascular hospitals

When the physicians and nurses on the cardiology team at Tufts Medical Center in Boston noticed a 40% increase in cost per case for congestive heart failure patients in 2013 due to longer length of stay and pharmaceutical use, they created a plan to address the cost issue while maintaining quality of care.

Using their data regarding length of stay for heart failure patients, they projected that those who received heart transplant surgery generally should be discharged post-surgery after seven days while those receiving ventricular assist device surgery should be released at 14 days. They also implemented protocols for when and how very expensive drugs should be used.

Dr. Marvin Konstam, chief physician executive at the hospital's cardiovascular center, said that with the length-of-stay goals in mind, physical therapy and getting patients walking around were started sooner, and they recovered faster. The changes reflect a decrease in overall average length of stay for heart transplant and ventricular assist device patients. The entire length of stay for heart transplant and ventricular assist device hospitalizations has decreased from 85 days in 2013 to 32 days in 2015. Since 2013, average cost per case for daily-non ICU care has decreased by $33,318 and pharmaceutical costs have decreased by $25,364. At the same time, survival rates exceed the national average. One-year survival rates for heart transplants at Tufts is 93.4% compared to 87.7% at the national level. One-year survival rates for ventricular assist device surgery is 83% compared to 81% nationally.

Similarly, at University of Wisconsin Hospitals and Clinics in Madison, monthly quality conferences assemble physicians and nurses to evaluate data regarding complications and testing. Cardiologists look at appropriate-use criteria and benchmarks from other hospitals to determine their own performance goals.

Intensive use of patient data for clinical and cost improvement are hallmarks of the hospitals that made this year's list of Truven Health Analytics' 50 Top Cardiovascular Hospitals in the U.S. Tufts, the University of Wisconsin and other hospitals that made this year's list are regularly monitoring data and measuring performance against quality benchmarks. That's key to their improvement and cost-efficiency efforts. But implementing changes based on data is a challenge, their leaders acknowledge.

Truven's 17th annual report reviewed 1,017 hospitals that provide both medical and surgical treatment for heart disease. The 50 hospitals on Truven's top-performing list scored higher than their peers on clinical outcomes and cost for heart attack and heart failure treatments, as well as coronary bypass and angioplasty surgeries. Like last year, the hospitals are divided into three categories—15 teaching hospitals with a cardiovascular residency program, 20 teaching hospitals without a cardiovascular residency program, and 15 community hospitals.

Thirty-six of the 50 top hospitals are part of larger health systems, Truven said.

The hospitals are evaluated based on 20 performance measures from the most recent data from the Medicare Provider Analysis and Review file, CMS Hospital Compare and Medicare cost reports. Truven includes six risk-adjustment clinical outcome measures, including mortality and complications rates; two clinical-process measures, including one for patients who undergo coronary bypass surgery and receive an internal mammary artery graft; four extended-outcomes measures, including 30-day mortality and 30-day readmission rates; and eight efficiency measures, including average length of stay and average cost per case for heart attack, heart failure, coronary artery bypass graft and coronary angioplasty treatments.

Truven's 50 top cardiovascular hospitals had better lengths of stay and mortality rates than their peers on a risk-adjusted basis. They had 27% fewer patient deaths from heart failure, 20.2% fewer patient deaths from heart attack, and 35.5% fewer deaths for patients undergoing coronary bypass surgery.

Lengths of stay were also shorter by 15.2% for heart attack patients and 10.9% shorter for heart failure patients.

Besides having better processes and outcomes, Truven's 50 top cardiovascular hospitals had lower average costs compared with their peers on a risk-adjusted basis. Heart attack treatment cost $1,946 less per patient, and heart failure treatments cost $1,235 less. Coronary bypass surgery cost $6,151 less per patient, and coronary angioplasty cost $2,642 less.

“This year's study shows substantial difference in average cost per case and that is indicative of great efficiency,” said Jean Chenoweth, senior vice president of performance and improvement. Improving 30-day mortality and readmission rates were of particular interest to hospitals this year because they face financial penalties from the CMS for poor outcomes, said Dr. Janet Young, a lead scientist for Truven.

According to Truven's analysis, if all cardiovascular hospitals performed at the same level as the top 50 hospitals, 8,000 more lives could be saved annually, nearly 3,500 heart complications could be avoided, and more than $1.3 billion in healthcare spending could be eliminated.

As hospitals focus on improving quality and efficiency in the highly competitive field of cardiovascular care, the regular use of data to evaluate outcomes is essential, said Dr. Ashish Jha, a professor of health policy and management at the Harvard School of Public Health who studies quality and patient safety. “We have a lot of evidence about what works in cardiovascular care, more so than any other condition,” he said. “A lot of hospitals are paying attention to data around how well they're practicing evidence-based medicine and how well they're improving. It's one of the key elements of improvement.”

Jha added that it's “particularly challenging” to be one of the top cardiovascular hospitals because cardiac care has improved nationally. Mortality rates have declined for almost every cardiac condition. The improvement in cardiovascular care over the last decade is “one of the biggest success stories in American medicine.”

Nevertheless, heart disease remains the leading cause of death in the U.S., killing 610,000 people annually, according to the latest data from the Centers for Disease Control and Prevention. Coronary heart disease is the most common condition. The healthcare services, medications and missed days of work associated with coronary heart disease cost the U.S. $108.9 billion annually, according to the CDC.

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.