How do teach­ing hos­pi­tals and com­mu­nity hos­pi­tals com­pare? They all have their strengths, weak­nesses.

Dif­fer­ent types of hos­pi­tals ex­cel— and fall short— based on which mea­sures are cited

Modern Healthcare - - MODERN HEALTHCARE - By Lola Butcher

Ma­jor teach­ing hos­pi­tals have the low­est mor­tal­ity rate of all hos­pi­tal cat­e­gories, ac­cord­ing to a new study con­ducted by Tru­ven Health An­a­lyt­ics. But they also have sig­nif­i­cantly higher in­ci­dence of ad­verse pa­tient-safety events and com­pli­ca­tions.

Those seem­ingly in­con­gru­ent find­ings might be ex­plained, in part, by con­sid­er­ing the pa­tient pop­u­la­tion that ma­jor teach­ing hos­pi­tals serve and their ca­pac­ity for ad­dress-

-ing com­pli­ca­tions, says Vinita Bahl, di­rec­tor of the Of­fice of Per­for­mance As­sess­ment and Clin­i­cal Ef­fec­tive­ness for the 919-bed Univer­sity of Michi­gan Health Sys­tem, Ann Ar­bor.

“Ma­jor teach­ing hos­pi­tals treat pa­tients that are more com­plex and more se­verely ill than non­teach­ing hos­pi­tals, and th­ese pa­tients are at higher risk for com­pli­ca­tions,” Bahl says in an e-mail. “Though it seems like a para­dox, the data sug­gest that ma­jor teach­ing hos­pi­tals are equipped to … ef­fec­tively res­cue pa­tients through timely recog­ni­tion and man­age­ment of com­pli­ca­tions once they oc­cur.”

Tru­ven, which rec­og­nizes high-per­form­ing hos­pi­tals through its an­nual 100 Top Hos­pi­tals list, con­ducted the anal­y­sis ex­clu­sively for Mod­ern Health­care to ex­plore whether hos­pi­tal size or teach­ing sta­tus af­fects per­for­mance on key qual­ity and cost met­rics. The take­away: No hos­pi­tal cat­e­gory has con­sis­tently su­pe­rior per­for­mance com­pared with the other classes, but sig­nif­i­cant dif­fer­ences in per­for­mance were found in al­most ev­ery mea­sure.

Ac­cord­ing to Tru­ven, ma­jor teach­ing hos­pi­tals are those with at least 400 beds in ser­vice and a high in­tern- and res­i­dent-per-bed ra­tio, while teach­ing hos­pi­tals have 200 or more beds and a less-in­tense train­ing com­po­nent. Large com­mu­nity hos­pi­tals are those with 250 or more acute-care beds; medi­um­sized com­mu­nity hos­pi­tals have 100 to 249 beds; and small com­mu­nity hos­pi­tals have 25 to 99 beds.

“We’re re­ally demon­strat­ing that each cat­e­gory of hos­pi­tals has a dif­fer­ent set of is­sues,” says Jean Chenoweth, Tru­ven’s se­nior vice pres­i­dent of per­for­mance im­prove­ment and the 100 Top Hos­pi­tals pro­gram.

David Foster, prin­ci­pal in­ves­ti­ga­tor for Tru­ven’s Cen­ter for Health­care An­a­lyt­ics, says the study is note­wor­thy be­cause it is one of the first to ex­am­ine the ef­fect of struc­tural char­ac­ter­is­tics—in this case, size and teach­ing sta­tus—on hos­pi­tal per­for­mance. With the in­creas­ing fo­cus on value in health­care de­liv­ery, the find­ings might pro­vide clues to where hos­pi­tal lead­ers need to fo­cus their ef­forts. For ex­am­ple, small and medium-sized com­mu­nity hos­pi­tals might need to work on re­duc­ing mor­tal­ity, while teach­ing hos­pi­tals need to im­prove pa­tient safety.

That said, struc­tural char­ac­ter­is­tics do not de­ter­mine a hos­pi­tal’s des­tiny. “There are hos­pi­tals that have rec­og­nized the is­sues spe­cific to their class of hos­pi­tal and de­vel­oped ways to achieve 100 Top national bench­mark per­for­mance,” Chenoweth says.

Kyle De­Fur, pres­i­dent of 873-bed St. Vin­cent In­di­anapo­lis Hos­pi­tal, a seven-time 100

Top teach­ing hos­pi­tal, be­lieves man­age­ment trumps struc­tural fac­tors in de­ter­min­ing the value of care a hos­pi­tal de­liv­ers.

“I think it has more to do with cul­ture and the fo­cus of the or­ga­ni­za­tion than it has to do with the size of an or­ga­ni­za­tion or even the kind of or­ga­ni­za­tion that it is,” De­Fur says. “You can make the ar­gu­ment that the larger the ship, the more time it takes to turn it. But I don’t think (suc­cess) is as size-re­lated as it is tied to the re­sources that are be­ing ded­i­cated to move the dial on those value-based mea­sures.”

Tru­ven an­a­lyzed the per­for­mance of 2,922 hos­pi­tals buck­eted into five classes de­fined by the num­ber of acute-care beds in ser­vice and teach­ing sta­tus: ma­jor teach­ing, teach­ing, large com­mu­nity, medium com­mu­nity and small com­mu­nity. Data sources were Medi­care Provider Anal­y­sis and Re­view (MedPAR) pub­lic use files for 2010 and 2011, the CMS’ Hos­pi­tal Com­pare data­base and Medi­care cost re­ports. Note­wor­thy find­ings in­clude:

Aver­age length of stay in­creases with fa­cil­ity size. With an ALOS of 5.31 days, ma­jor teach­ing hos­pi­tals had sig­nif­i­cantly longer lengths of stay than any other class. Small com­mu­nity hos­pi­tals had the short­est, at 4.83 days.

Ma­jor teach­ing in­sti­tu­tions have sig­nif­i­cantly higher in­pa­tient ex­penses per dis­charge—an aver­age of $7,303—than the other groups. The anal­y­sis found that small hos­pi­tals had the sec­ond-high­est in­pa­tient ex­pense per dis­charge, $6,428. Large com­mu­nity hos­pi­tals had the small­est aver­age fig­ure at $6,092.

Large com­mu­nity hos­pi­tals had the high­est op­er­at­ing profit mar­gin—7%—in 2011, while small com­mu­nity hos­pi­tals had the low­est at 3.5%. Ma­jor teach­ing hos­pi­tals had a 4.5% mar­gin.

All classes of hos­pi­tals com­ply with the CMS’ core mea­sures at be­tween the 95th and 97th per­centile, mean­ing that more than 95% of all pa­tients are treated with ev­i­dence-based level of care for those mea­sures.

Tru­ven in­ves­ti­gated hos­pi­tal per­for­mance on a sin­gle Hos­pi­tal Con­sumer As­sess­ment of Health­care Providers and Sys­tems (HCAHPS) sur­vey ques­tion: Would you rec­om­mend this hos­pi­tal to your fam­ily and friends? Smaller teach­ing hos­pi­tals had the high­est score, on aver­age, among the five classes, while medi­um­sized com­mu­nity hos­pi­tals scored the low­est.

Ted Townsend, pres­i­dent and CEO of 363bed Uni­tyPoint Health-St. Luke’s Hos­pi­tal in Cedar Rapids, Iowa, reads the Tru­ven anal­y­sis

as good news for smaller teach­ing hos­pi­tals, which out­per­form ma­jor teach­ing hos­pi­tals on ev­ery qual­ity and cost met­ric in the study.

That means smaller teach­ing hos­pi­tals could have a nat­u­ral ad­van­tage un­der the CMS’ value-based pur­chas­ing for­mula, which ties pay­ment rates to qual­ity, cost and pa­tient ex­pe­ri­ence mea­sures.

“We have some ed­u­ca­tion go­ing on, but a far greater de­gree of ex­pe­ri­ence at the bed­side on a day-in, day-out ba­sis,” he says. “And that’s the sweet spot from a cost stand­point as well, be­cause we don’t have to have all the in­fra­struc­ture of a ma­jor aca­demic med­i­cal cen­ter, but we do have a lot of the value that comes from teach­ing peo­ple.”

The Univer­sity of Michi­gan Hos­pi­tals & Health Cen­ters has been named to the 100 Top Hos­pi­tals list eight times, and Bahl agrees that the Tru­ven anal­y­sis might pro­vide hints about how ma­jor teach­ing hos­pi­tals are likely to fare un­der the govern­ment’s value-based pur­chas­ing pro­gram. Al­though Tru­ven’s anal­y­sis shows that ma­jor teach­ing hos­pi­tals per­form rel­a­tively well on the one will­ing­ness-to-rec­om­mend HCAHPS mea­sure, aca­demic med­i­cal cen­ters gen­er­ally tend to score lower than other hos­pi­tal classes on the full HCAHPS sur­vey, Bahl says. Fur­ther, the Tru­ven anal­y­sis shows that ma­jor teach­ing hos­pi­tals had no ad­van­tage over other classes in terms of core-mea­sure per­for­mance.

“In value-based pur­chas­ing, where even small dif­fer­ences in mea­sure­ment re­sults can trans­late to large dif­fer­ences in over­all pro­gram per­for­mance, ma­jor teach­ing hos­pi­tals may not thrive, but they can be com­pet­i­tive,” Bahl says.

Medium-sized com­mu­nity hos­pi­tals had two po­ten­tially wor­ri­some find­ings in the Tru­ven anal­y­sis: At 13%, their 30-day mor­tal­ity rate was the high­est of any class while their will­ing­ness-to-rec­om­mend HCAHPS score was the low­est. How­ever, the medium-sized hos­pi­tals’ mor­tal­ity rate was just one-tenth of a point higher than the small-hos­pi­tal cat­e­gory.

With be­tween 100 and 249 beds, hos­pi­tals in that class are chal­lenged to have staff ded­i­cated to pa­tients based on their med­i­cal sit­u­a­tion, such as ortho­pe­dic surgery ver­sus can­cer surgery, says Dave Graeb­ner, pres­i­dent of 130bed Aurora She­boy­gan (Wis.) Me­mo­rial Med­i­cal Cen­ter. The need to con­gre­gate pa­tients on med­i­cal/sur­gi­cal floors may ex­plain the pa­tient-sat­is­fac­tion score.

Aurora She­boy­gan has made the 100 Top Hos­pi­tals ros­ter five times, prov­ing that

medium-sized fa­cil­i­ties can over­come chal­lenges iden­ti­fied in the study. Graeb­ner cites two ad­van­tages hos­pi­tals in that class may have as they seek to de­liver high-value care: the abil­ity to fo­cus on a well-de­fined pa­tient pop­u­la­tion—in his case, She­boy­gan’s 145,000 res­i­dents—and the abil­ity to work closely with a rel­a­tively small med­i­cal staff to pro­vide pa­tient care at the right place at the right time.

Aurora She­boy­gan’s med­i­cal staff has only about 150 physi­cians, all of whom are em­ployed by the Aurora sys­tem. Graeb­ner says that small num­ber of physi­cians and physi­cian em­ploy­ment work to­gether to sup­port the hos­pi­tal-physi­cian align­ment needed to suc­ceed in the CMS’ value-based pur­chas­ing pro­gram.

The dif­fer­ent strengths and weak­nesses of the var­i­ous hos­pi­tal classes could re­flect the dif­fer­ent roles they play in the health­care sys­tem, Chenoweth says. For ex­am­ple, the fact that small and medium-sized com­mu­nity hos­pi­tals have higher mor­tal­ity than larger hos­pi­tals might not re­flect the qual­ity of care they de­liver but rather the lack of hospice ser­vices in their com­mu­ni­ties.

“We need to do more re­search to un­der­stand why those mor­tal­ity rates are higher … but my sus­pi­cion is that they are pro­vid­ing some end-of-life care,” she says.

The Univer­sity of Michi­gan Hos­pi­tals & Health Cen­ters in Ann Ar­bor, one of the ma­jor teach­ing hos­pi­tals on Tru­ven Health’s 100 Top Hos­pi­tals list for 2013, has made the ros­ter eight times.

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