Challenging convention in cardiac care

When doctors at Morton Plant Hospital learned in 2013 that 1 in 10 of their coronary artery bypass graft patients spent extended time on breathing machines—a higher proportion than other hospitals—they went to work.

Was one particular physician to blame? Was it something about a particular set of patients? Doctors at the 687-bed teaching hospital in Clearwater, Fla., analyzed the data and determined that they needed to identify patients prone to prolonged ventilator time so they could spend more effort preparing them for the operation.

If a patient had lung disease, for instance, that patient would see a pulmonary doctor to optimize the lungs prior to cardiac surgery. And after surgery, critical-care doctors were brought in. By the first six months of 2016, prolonged ventilator use was down to 4.1% of bypass patients, according to Dr. Mahesh Amin, the hospital’s medical director of cardiology.

Morton Plant Hospital learned about its prolonged ventilation ratio from the Society of Thoracic Surgeons, which maintains a registry many hospitals use to gauge performance. The hospital, which for the 15th time has landed on Truven Health Analytics’ list of 50 Top Cardiovascular Hospitals in the U.S., deploys multidisciplinary teams to review cases, decide on a course of care, and track patients together. The hospital constantly scours data to identify areas with room for improvement.

This year’s list of top cardiac hospitals, now in its 18th edition, is a mix of oldtimers, like Morton, and newcomers, like Kootenai Health in Coeur d’Alene, Idaho. The hospitals are rural and urban, in the Southeast and Northwest and Midwest, but traits they share are that they are constantly tracking data and assessing their performance. They also take pride in offering teambased, multidisciplinary and patient-centered care.

This approach is critical, doctors and administrators say, as they treat ever-sicker patients and balance the demands of standardized, evidence-based practices with the need for individualized care.

For the first time, Truven’s analysis also included a five-year trends report of cardiovascular hospitals across the U.S.

“Cardiovascular care is standardizing very rapidly. Physicians and hospitals are trying to squeeze out variation across the board,” said Jean Chenoweth, senior vice president of performance and improvement at Truven. “There’s still a lot of inconsistency in care, but it’s really improving.”

All hospitals across the U.S. face a broad array of challenges. The ones that made the top 50 in cardiac care are the ones that figured out how to navigate the unique challenges of a service line crucial to hospitals’ overall quality performance and bottom lines.

Truven uses publicly available data to rank hospitals on outcomes and costs of cardiac care. It focuses on short-term, acute care for a broad span of patients receiving both medical and surgical treatment for heart attacks and heart failure. To be included in the study, hospitals have to handle a minimum of 30 unique cases per group, such as nonsurgical heart attack patients or coronary artery bypass graft surgery, or CABG.

The analysis excluded specialty hospitals, those with fewer than 25 beds, and hospitals whose average Medicare length of stay exceeded 30 days. Hospitals lacking necessary data were also omitted.

This year, Truven judged 1,012 hospitals in three categories: 229 teaching hospitals with cardiovascular residency programs, 306 teaching hospitals without such residencies and 477 community hospitals. It used 21 performance measures covering clinical outcomes, processes, extended outcomes and efficiency (See chart at left).

To gauge efficiency, Truven used the severity-adjusted averages for length of stay and cost per case for heart attacks, heart failure, coronary bypass and angioplasty patients.

The data came from Medicare Provider Analysis and Review data, the CMS’ Hospital Compare website, and Medicare cost reports. Medicare data compose a representa-

tive picture, according to Truven, because roughly twothirds of all patients who receive medical care for heart attacks or heart failure are Medicare beneficiaries. So are about half of all coronary angioplasty and bypass patients.

The top 50 hospitals outscored their peers on mortality, complications, clinical processes and extended outcomes such as 30-day mortality and readmissions. On average, their procedures cost less, and patients had shorter hospital stays.

The Truven five-year trends analysis found that for the most part, cardiac care at hospitals is improving. Mortality rates for heart attacks significantly improved at 6.5% of hospitals, remained unchanged at 93.1% of hospitals, and worsened at 0.3% of hospitals from 2011 to 2015. Hospitals made even greater gains in 30-day mortality rates for heart attack patients—29% of hospitals improved in that area, 66.9% did not change, and 3.6% worsened.

The sole exception was in 30-day mortality for heart failure, where 6.3% of hospitals improved and 16.2% worsened. Readmission rates for heart attack and heart failure, meanwhile, improved at a whopping 50.5% and 39.5% of hospitals, respectively, and remained the same at 49.1% and 60% of hospitals.

The CMS in 2012 began penalizing hospitals for excessive 30-day readmission rates. “That shows that hospitals are paying attention to what CMS is looking at,” said Dr. Janet Young, a lead scientist at Truven.

Some research suggests that hospitals with higher mortality rates have fewer readmissions because the patient pool has been reduced. That also raises the question of whether hospitals’ efforts to cut down readmissions are inadvertently killing patients, perhaps because hospitals, in their efforts to tamp down readmissions rates, are refusing to readmit patients even though they may need rehospitalization. “That would be not in keeping with what CMS intended to do,” Young said, calling for further study in that area.

Shortening stays

Within the past six months, the cardiology division at Steward St. Elizabeth’s Medical Center, a teaching hospital in Brighton, Mass., which has appeared on the Truven top 50 list five times in 18 years, observed that patients receiving transcatheter aortic valve replacements spent five or six days in the hospital—longer than patients in other hospitals. So the hospital deconstructed the entire stay, scrutinizing 12hour chunks of time and asked: What can we streamline?

Rarely does a single thing keep a patient in the hospital. “It’s usually a combination of things, and in order to figure out how to affect those things, you have to break it down,” said Dr. Joseph Carrozza, chief of the cardiology division at Steward St. Elizabeth’s. The hospital developed a timeline looking at the first 12 hours of stay, then the next 12. Could any of what happened between 12 and 24 hours happen during the zero to 12-hour window?

One conclusion was that some patients could spend less time on breathing machines, which slow their recovery. “The sooner we’ve found that we can get patients out of bed, the sooner we can get them to start doing rehab in the hospital, which gets them out the door quicker,” Carrozza said. The hospital hopes to trim average length of stay to two or three days.

Such improvements are a balancing act, and they require everyone in the hospital to pitch in. Nursing staff play a huge role in removing catheters and tubes placed during procedures, switching patients to oral medications from intravenous, and above all, noticing when a patient isn’t ready for a change in care.

“It’s very easy to change processes in hopes of making them more efficient, but at the end of the day you have to make sure you’re not compromising patient care,” Carrozza said. The key to keeping patients safe, he said, is to accept that not all best practices and standards can be met all the time.

For hospitals, knowing when to allow evidence to guide practices, even if they depart from what doctors have always done, and when to ease off if such protocols should not apply to individual patients, is key.

Data determine differentiation

At Carilion Roanoke (Va.) Memorial Hospital, using data has improved care and accelerated change, said CEO Steve Arner. “What I’ve witnessed is much more urgency behind things,” he said.

In 2005, 59% of Carilion Roanoke’s coronary artery bypass graft patients received blood transfusions, which studies have linked to increased mortality and complications. The hospital used a multidisciplinary approach, developing strategies to conserve blood using evidence-based practices. By the end of 2015, the percentage of bypass patients who received transfusions was down to 22%.

Kootenai Health, in Idaho, which this year made the top 50 list for the first time, has also improved transfusion practices, conserving blood and lowering thresholds. Those changes have created one subtle but significant hurdle: getting used to inconveniences as patients require more time or need medications switched.

Dr. Rob Burnett, a cardiothoracic surgeon at Kootenai, said doctors also had to adjust to patients who were a little more anemic than they were accustomed to.

Kootenai’s location in rural north Idaho also poses challenges. Long distances and inclement weather sometimes prevent patients from making follow-up visits or getting home healthcare that can reduce their odds of seeking readmission. So Kootenai has a program where a nurse calls and checks on patients, reminding them to take their medications and check incisions. Even then, patients sometimes lack cell service or landlines, Burnett, the surgeon, said.

Treating sicker, more complex patients—diabetics, smokers, obese people—requires closer surveillance. For instance, at Longview (Texas) Regional Medical Center, if a patient is found to have peripheral artery disease, in which plaque builds up in arteries reaching critical parts of the body, doctors will bring them back within 14 days to evaluate other parts of the body that might be at risk.

“The fact that people are sicker still gives us the opportunity to take care of them,” said Dr. Samir Germanwala, a cardiologist at the 230-bed community hospital, which made the Truven list for the first time this year. “When they go home, the key difference is that you really have to follow up with them as an outpatient and take care of other things that could go wrong.”