California 'falling behind as a leader' in cardiovascular, yet study finds cardiac care improving throughout U.S.

Not a single California hospital made the "top 100" list for cardiovascular care in a study released by Thomson Healthcare late last year. The question is why, given this state's large population (36 million) and proportionally large number of cardiovascular care units in hospitals throughout the state.

Those that made the list did so because the complex, detailed study found that the top 100 cardiovascular units treat heart patients in less time, at a lower cost and with lower mortality rates.

The final selection included 30 teaching hospitals with cardiovascular residents, 40 teaching hospitals without cardiovascular residents, and 30 regional community hospitals, according to Jean Chenoweth, senior vice president for performance improvement and 100 top programs for Thomson.

Some California hospitals that have made the list in the past — including Stanford University Hospital and UC Davis Medical Center — just didn't have the winning numbers in 2007, Chenoweth said.

"What the data has been saying is that California has been falling behind as a leader," Chenoweth said. "The performance of hospitals elsewhere had higher benchmarks."
"Since the quality of cardiovascular care is improving all around the country, the differences among hospitals are getting smaller," Chenoweth added. "It's tight to get on the top 100 list."

According to the study, the 100 Top Hospitals had:

•Hospital stays that were 12 percent shorter, on average, than peer hospitals (5.14 days compared to 5.85 days).
•Costs that averaged 13 percent — or about $2,000 — less per case than peer hospitals.

The study examined the performance of nearly 1,000 U.S. hospitals by analyzing their outcomes for eight measures related to congestive heart failure (CHF), heart attacks (acute myocardial infarction or AMI), coronary artery bypass grafts (CABGs), and percutaneous coronary interventions (PCIs), such as angioplasties. The final 100 came out with the best numbers, although in many cases, the differences between the top 100 and top 200 were minimal.

The study, which has been conducted for nine consecutive years, found that six states were ranked in the top quintile in both 2004 and 2006: Kentucky, North Dakota, Ohio, South Dakota, Washington state and Wisconsin. Seven states were at the bottom of the list in both studies: Alaska, Hawaii, Nevada, New Jersey, New York, South Carolina and Wyoming. In 2005, some other states were included in the top and bottom lists.

The three most populous states — California, New York and Texas — placed in the two lowest quintiles in both studies.

The study found that the likelihood of a hospital patient receiving cardiovascular care that meets minimum standards varies substantially, depending on the state in which the patient seeks treatment, according to the analysis by Solucient, a Thomson healthcare business.

Solucient scored facilities in eight key performance areas: risk-adjusted medical mortality, risk-adjusted surgical mortality, risk-adjusted complications, core measures score, percentage of CABG patients with internal mammary artery use, procedure volume, severity-adjusted average length of stay and wage- and severity-adjusted average cost.

Most of the top 100 hospitals were in New England states and the Midwest, particularly Michigan and Ohio.

When questioned about the geographic skewing, Chenoweth said hospitals tend to compete with each other within a state and this competition raises each other's standards. If hospitals in a state like California only compete with each other, their standards may not be as high as in other states.

Indeed, California ranked a 90.3 rating in the Thomson study, falling behind many other states and coming in slightly below hospitals in Alabama.

The Solucient study showed that the Northeastern states were the best in meeting the CHF (congestive heart failure) and AMI (acute myocardial infarction) standards, with five of the six New England states demonstrating exceptional performance. States in the southern region of the country performed the worst, with nearly half performing in the bottom quartile.

The top 100 cardiovascular winners "have set national benchmarks for clinical process, outcomes and efficiency, as well as reasonable cost," according to Chenoweth. These hospitals also meet volume standards for both percutaneous coronary interventions and coronary artery bypass grafts," she said.

The study on cardiovascular services said it objectively measures performance against key criteria and the nation's top-performing acute-care hospitals.

Among the study's other findings, according to a news release by Thomson Healthcare:

•If peer hospitals (non-winners) provided the same quality of health care as the 100 Top Hospital facilities, survival rates could increase by more than 8,000 patients each year.
•Complications of care would also decrease in peer hospitals. Approximately 575 additional patients could be complication-free.
•The average 100 Top Hospitals cardiovascular winners use the recommended core measures standards for most (95 percent) of its acute mycordial infarction patients. Of the hospitals that did not make the top 100 list, only 93 percent of the patients received the core standards. So the differences between the winning and losing hospitals were two percentage points.
•Both medical and surgical cardiovascular patients experience markedly higher survival rates at winning hospitals. For example, winning hospitals had 21 percent fewer deaths than expected for CABG patients while peer hospitals had only 1 percent fewer deaths than expected.
•Winning hospitals performed up to 80 percent more PCIS than their peers, and about 50 percent more CABG. Previous research has shown that procedure volume is a critical factor in outcomes for cardiovascular patients. The more procedures perfomed in any area,the better the hospitals seemed to score.
•Benchmark hospitals are proving more efficient in treating cardiovascular patients. The average 100 Top Hospitals Cardiovascular winner discharges patients half a day earlier and at an average cost that is about 13 percent less than its peers.

Chenoweth did say that in early spring Thomson will release another report on the top 100 hospitals in the nation and initial figures suggested some California hospitals would make the list.

—By Diana Diamond

Diana Diamond is the editor of the Healthcare Journal. You can reach her at diana@healthjournalnorcal.com.

Diana Diamond is the editor of the Healthcare Journal. You can reach her at diana@healthcarejournalnorcal.com