Cardiac study shows wide performance gaps
Treatment differs among high-volume hospitals
Consumers have been told that finding a hospital that does a lot of the procedure they are about to have is a key to good treatment. But a study by the Evanston, IL, health care consulting firm Solucient found that even among hospitals that do a lot of angioplasty or bypass grafts, there are significant gaps in outcomes and complication rates.
The annual 100 Top Cardiovascular Hospitals survey, released in July, found that if peer hospitals in the study achieved the same success as the best performers, they could cut procedure mortality rates by up to a quarter, cut costs per cardiology case by more than $2,000, and cut postoperative mortality by up to 20%. (To see chart, click here.)
"Volume has been shown to be a critical factor in determining which hospitals have better outcomes for certain procedures," explains Jean Chenoweth, executive director of the Solucient Institute. "But this analysis, which was restricted to hospitals with high volumes of cardiac patients, clearly indicates that volume alone does not ensure the best results, at least in terms of mortality, hemorrhage, and infection. This study is a call for action. The industry needs to provide consumers with a broader group of measures for describing best practices in all hospitals."
Among the most significant differences found between the winners and the nonwinners in the study are:
• When performing percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass surgery (CABG), the rate of post-operative infection is an average 21% lower among all top hospitals, and an average 34% lower at top community hospitals.
• Heart attack patients have a 7% lower risk-adjusted mortality rate at top-performing hospitals. Among community hospitals, the rate is 11% lower.
• The use of stents during PTCA increased from 63% in last year’s study to 79% this year.
The data used in the study comes from DRG data from Solucient and hospital databases, as well as Medicare Provider Analysis and Review (MedPar) data. They winners include 25 teaching hospitals with cardiovascular residency programs, 45 teaching hospitals without such programs, and 30 community hospitals. In order to qualify for inclusion, there were volume criteria that had to be met. At least 100 reported Medicare cases of acute myocardial infarction (AMI), at least 125 reported Medicare patients in the PTCA diagnostic group, and at least 125 reported Medicare CABG patients. The hospitals that met those criteria were then analyzed according to the following measures:
• AMI patient mortality index;
• risk-adjusted CABG patient mortality;
• risk-adjusted PTCA patient mortality index;
• risk-adjusted post operative patient mortality index;
• combined risk-adjusted postoperative infection index (postoperative is defined by the presence of surgical discharge DRG), risk-adjusted postoperative hemorrhage index, and percentage of PTCA patients with CABG surgeries during the same admission;
• percentage of CABG patients with internal mammary artery use;
• severity-adjusted average length of stay;
• wage and severity-adjusted average cost.
One of the new additions to the 100 Top Hospitals this year is the 468-bed Robert Wood Johnson University Hospital in New Brunswick, NJ. According to Clifton R. Lacy, MD, senior vice president for medical affairs and chief of staff at the facility, being named is a big thrill to the facility, which has a stated goal of making its heart center one of the best in the nation. "There are a lot of surveys and lists," Lacy says. "What makes this valuable is that Solucient is well-known, and its measures and methodology are recognized and well-respected. This isn’t just a beauty contest."
Not that he doesn’t take great pride in being among a list that includes Massachusetts General, the Cleveland Clinic, and Baylor. "We are younger than they are, but that’s whose company we want to be in. It’s very satisfying to know our patients get the same care you can find in those places."
Lacy says the reason why his facility made the list is "our attention to excellence from the top of the organization down. We use practice protocols; we benchmark against the best facilities anywhere." But along with striving toward excellence, Lacy says he and his colleagues also understand there is "no perfect. We keep reevaluating and recognize that medicine is a moving target."
Chenoweth says he hopes that people will realize from this survey that although volume is a good indicator to look at, there is more to judging a facility than looking at the number of cases it handles for each diagnostic related group. "Even in material generated by groups that believe we should look closely at volume, they say outcomes data, when available, is a superior datum to look at," she says. "But there are still areas of the country where employers look most closely at volume. And this study shows it’s a mistake to judge solely on that. It is our belief that the study helps bring a little reason to the zest of people who are trying to guide consumers. Outcomes are the result of a variety of factors, and volume is just one of them."
The other big story Chenoweth sees in this year’s data is that everyone is using stents. "In 1997/1998, top hospitals were using significantly more stents than their nonwinner counterparts," she says. "This year there is almost no difference in their use. That has to be good for the patients."
Those who look closely at this survey should note that next year it will be deeper, Chenoweth says. "We are adding some deeper, more clinical data elements," she says. Because of the merger last year between HCIA-Sachs and HBS International to create Solucient, Chenoweth says there is more access to larger databases that will help Solucient determine how practices are changing. "We want to find a way to use public data integrated with some survey data or data we ask participants to submit separately so we can increase the real clinical content and look beyond administrative data."
[For more information, contact:
• Jean Chenoweth, Executive Director, Solucient Institute and 100 Top Hospital programs, 1800 Sherman Ave., Evanston, IL 60201. Telephone: (800) 366-7526.
• Clifton R. Lacy, MD, Senior Vice President for Medical Affairs and Chief of Staff at Robert Wood Johnson University Hospital, one Robert Wood Johnson Place, New Brunswick, NJ 08903. Telephone: (732) 937-8897.
For more on the survey, visit the 100 Top Hospitals web site at www.100tophospitals.com.]
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