[Research set-up concerning the effectiveness of heart failure clinics in the Netherlands]

In the Netherlands, the number of patients with heart failure is increasing. Several heart failure management programs have been initiated to reduce the number of readmissions and to improve the quality of care for these patients. However, conclusive data have yet to be provided. In the 'Coordinating study evaluating outcomes of advising and counselling in heart failure', started in 16 Dutch hospitals, 1050 heart failure patients have been randomised into 3 arms: (a) care as usual, (b) care as usual + basic education and support, and (c) care as usual + intensive education and support. Patients will be recruited in 18 months with an 18 month follow-up. This study has three outcomes, namely, time to first major event (heart failure hospitalizations and death), quality of life, and costs.

The effect of financial pressure on the quality of care in hospitals

This paper examines the effect of financial pressure on hospital quality, using health outcomes after treatment for acute myocardial infarction (AMI) as quality indicators. The financial pressure variables are: fiscal pressure from the Prospective Payment System (PPS) for inpatient care, and changes in health maintenance organization (HMO) penetration at the county level. The study shows that both types of financial pressures adversely affect short-term health outcomes, but do not affect patient survival beyond 1 year after patients' hospital admissions. Furthermore, the impact of HMO penetration appears to differ from that of Medicare payment changes for certain hospitals because HMO penetration encourages price competition.

The return of the heart hospital. A hospital that specializes in providing cardiovascular services can meet community needs but will compete with existing community hospitals for market share

A hospital that provides cardiovascular services and embraces a heart-hospital brand and strategy can achieve competitive advantage. Providers that want to compete aggressively for cardiovascular services are developing a specialty-based carve-out strategy. A heart-hospital initiative can cannibalize revenues from a hospital's other programs and services. A successful heart-hospital strategy requires physician buy-in. A heart hospital needs a brand that customers will value.

AbioCor totally implantable artificial heart. How will it impact hospitals?

Although heart transplantation remains the most effective treatment for severe heart failure, there are far fewer donor hearts available than there are patients who could benefit from them. One approach to addressing this shortfall is the total artificial heart, or TAH. To date, however, no TAH design has been able to achieve one of the ultimate goals of heart replacement: to allow a patient to live a reasonably normal life without being connected to external machinery. A new design, the AbioCor TAH developed by Abiomed Inc., may make this goal achievable. Thanks to a power system that transfers energy through the skin without the aid of wires, the AbioCor--currently undergoing clinical trials in the United States--allows the patient to be completely mobile. The lack of transcutaneous wires also eliminates the primary source of the infections that have plagued TAH patients in the past. Though it is not without drawbacks, the AbioCor could represent a crucial advance in TAH technology. In this Technology Overview, we describe the operation of the AbioCor and discuss its likely impact on hospitals if it is approved for marketing in the United States. We also discuss a related cardiac-support technology: ventricular assist devices (VADs), which may also be used for permanent cardiac support someday.

The determinants of HMOs' contracting with hospitals for bypass surgery

OBJECTIVE

Selective contracting with health care providers is one of the mechanisms HMOs (Health Maintenance Organizations) use to lower health care costs for their enrollees. However, are HMOs compromising quality to lower costs? To address this and other questions we identify factors that influence HMOs' selective contracting for coronary artery bypass surgery (CABG).

STUDY DESIGN

Using a logistic regression analysis, we estimated the effects of hospitals' quality, costliness, and geographic convenience on HMOs' decision to contract with a hospital for CABG services. We also estimated the impact of HMO characteristics and market characteristics on HMOs' contracting decision.

DATA SOURCES

A 1997 survey of a nationally representative sample of 50 HMOs that could have potentially contracted with 447 hospitals.

PRINCIPAL FINDINGS

About 44 percent of the HMO-hospital pairs had a contract. We found that the probability of an HMO contracting with a hospital increased as hospital quality increased and decreased as distance increased. Hospital costliness had a negative but borderline significant (0.10 < p < 0.05) effect on the probability of a contract across all types of HMOs. However, this effect was much larger for IPA (Independent Practice Association)-model HMOs than for either group/staff or network HMOs. An increase in HMO competition increased the probability of a contract while an increase in hospital competition decreased the probability of a contract. HMO penetration did not affect the probability of contracting. HMO characteristics also had significant effects on contracting decisions.

CONCLUSIONS

The results suggest that HMOs value quality, geographic convenience, and costliness, and that the importance of quality and costliness vary with HMO. Greater HMO competition encourages broader hospital networks whereas greater hospital competition leads to more restrictive networks.

[Ad-hoc coronary angioplasty: organizational model, clinical results and costs]

BACKGROUND

Our center routinely employs the strategy of ad hoc percutaneous coronary intervention (PCI) after diagnostic catheterization in previously informed and prepared patients with anatomical and clinical indications for some years. The aim of this study was to evaluate clinical results and resource consumption of the ad hoc PCI strategy in our center.

METHODS

We evaluated the results and resource consumption of 783 PCIs performed between January 1, 1999 and June 30, 2001, divided into 642 (82%) ad hoc and 141 (18%) deferred PCIs. We analyzed the patients' in-hospital clinical and procedural characteristics, the 1 and 6-month outcomes and resource consumption (costs of materials, quantity of contrast medium, fluoroscopic time and duration of procedures) in the two groups.

RESULTS

Patients in the ad hoc group had more frequently previous PCI, hypertension, diabetes, acute coronary syndrome, single vessel disease, single lesion and single vessel PCI, stent use and direct stenting, use of glycoprotein IIb/IIIa inhibitors and hemostatic devices; those in the deferred PCI group had more frequently previous myocardial infarction, stable angina, elective programmed hospital admission for PCI and multilesion single vessel PCI. The clinical results were good: clinical success in 97% of cases, in-hospital major adverse clinical events occurred in 2%, non-Q wave myocardial infarction in 3.4% (creatine-kinase-MB > 3 times higher than the upper normal limit in serial routine controls), major vascular complications in 0.4%, 1-month and 6-month major adverse clinical events in 4 and 9% respectively, without any difference between the two groups. Ad hoc PCI resulted in less contrast medium use, a shorter procedure duration, lower costs and shorter fluoroscopy times with respect to deferred PCI plus diagnostic catheterization, although not statistically significant.

CONCLUSIONS

In our experience, ad hoc PCI was safe and effective. Costs were lower and less resources were required. Patients were satisfactorily assisted and the logistics and organization of the procedure were optimal.

All pumped up over cardiology

Cardiovascular services are one of the few remaining profit centers for hospitals, and as baby boomers age, the need for such care is skyrocketing. A good cardiology program enhances a hospital's reputation and patient volume. However, the pressures to expand and the cost of swiftly changing technology put hospitals that are trying to keep up in a tight squeeze, which raises the question: is the pulse of change in cardiology too rapid?

The impact of statistical adjustment on economic profiles of interventional cardiologists

OBJECTIVES

The objective of this study was to identify preprocedure patient factors associated with percutaneous intervention costs and to examine the impact of these patient factors on economic profiles of interventional cardiologists.

BACKGROUND

There is increasing demand for information about comparative resource use patterns of interventional cardiologists. Economic provider profiles, however, often fail to account for patient characteristics.

METHODS

Data were obtained from Duke Medical Center cost and clinical information systems for 1,949 procedures performed by 13 providers between July 1, 1997, and December 31, 1998. Patient factors that influenced cost were identified using multiple regression analysis. After assessing interprovider variation in unadjusted cost, mixed linear models were used to examine how much cost variability was associated with the provider when patient characteristics were taken into account.

RESULTS

Total hospital costs averaged $15,643 (median, $13,809), $6,515 of which represented catheterization laboratory costs. Disease severity, acuity, comorbid illness and lesion type influenced total costs (R(2) = 38%), whereas catheterization costs were affected by lesion type and acuity (R(2) = 32%). Patient characteristics varied significantly among providers. Unadjusted total costs were weakly associated with provider, and this association disappeared after accounting for patient factors. The provider influence on catheterization costs persisted after adjusting for patient characteristics. Furthermore, the pattern of variation changed: the adjusted analysis identified three new outliers, and two providers lost their outlier status. Only one provider was consistently identified as an outlier in the unadjusted and adjusted analyses.

CONCLUSIONS

Economic profiles of interventional cardiologists may be misleading if they do not adequately adjust for patient characteristics before procedure.

[Expectations and satisfaction of patients during inpatient treatment]

PURPOSE

Aim of the study was to examine the expectations of patients at the beginning and the satisfaction at the end of a hospital stay. The hospital settings were standardised.

METHODS

510 patients on the cardiological ward were asked to fill in a questionnaire on the first and last day of their stay.

RESULTS

The admitted patients stated clear expectations in respect of the hospital facilities and staff. The most important aspects for the patients were the qualification of staff and the time physicians and nurses would devote to the patient, and the medical and technical equipment of the hospital. Beds per room, food, length and costs of the stay were less important in patients' expectations. On the day of discharge, the patients were very satisfied with the staff and medical equipment, in contrast to a low satisfaction regarding additional fees and the number of beds per room (three).

CONCLUSIONS

Since cost-benefit is a basic need in running a hospital today, financial resources should be enhanced in the spheres which are equally medically important for fulfilling the expectations of the patients. Therefore, the number of staff and the qualification of the medical professionals should be financed instead of supporting architectural and room design. Accordingly, the patients' main criteria for choosing a hospital is the medical equipment provided and the qualification of the medical staff. In conclusion, these aspects should be publicized for meaningful decision-making. Medical professionals should be encouraged to inspire competence and to spend as much time as possible with each individual patient.

Implementing 12-hour shifts on a cardiology nursing development unit

This article, the first of two parts, discusses the implementation of 12-hour shifts using a locally devised nursing development unit (NDU) framework. A literature review and force-field analysis were undertaken to plan, implement and evaluate the introduction of the 12-hour system. The literature review identified five broad categories: effect on care delivery; nurse education; cost-effectiveness; impact on staff; and implementation strategies. It also ascertained that the most successful methods of implementation were those that gained the cooperation of staff. The force-field analysis identified the restraining forces (e.g. tiredness, the European Working Time Directive and staff views) and therefore allowed the change agent to concentrate his limited time on combating these restraining forces. The second part of this series will examine the evaluation and audit of the 12-hour shift system.

Consultant identifies four 'megatrends' in cardiovascular business arena

Despite ambivalent situations in the cardiovascular business, Jeffrey Frazier of John Goodman & Associates identifies four operational trends that are affecting the growth of heart programs.

Creating cost-efficient initiatives in social work practice in the cardiac program of an acute care hospital

All three cost-saving initiatives--the creation of a one-page application form to streamline the rehabilitation application process, the use of the resource specialist to assist with applications, and the development of an information package on cardiac rehabilitation--reflect a process whereby a creative idea, generating planning, activities, and follow-up resulted in a measurable effective change in practice. This process truly translated strategy into action (Kaplan, 1996) and is vital to the current rethinking in health care of how best to do our work (Coan, 1994). Because of this process, social workers in the cardiovascular surgical division of the cardiac program are better equipped to respond to the psychosocial needs of a growing cardiac population in a fiscally restrained environment.

The effect of a 'fast-track' unit on the performance of a cardiothoracic department

OBJECTIVE

The objective of this study was to describe the impact of a 'fast-track' unit, combined with a computerised system for information collection and analysis, on the clinical practice and finance of a cardiothoracic department over the first 12 month period of its application.

METHODS

Within 12 months, starting December 1996, 642 major cardiothoracic cases were performed at the Cardiothoracic Department, St Mary's Hospital, London, after the establishment of a 3-bed 'fast-track' unit, which was supported by a computerised system for admission planning and a pre-admission clinic. The main outcome measures were operating numbers, financial income, patient recovery and operative mortality.

RESULTS

The 'fast-track' unit resulted in an increase of the operating numbers (11.3% increase in major cardiac cases) and income (38%), as compared with the year before. Some 525 patients out of 642 (81.8%) were scheduled for the 'fast-track' unit and 492 (93.7%) were successfully 'fast-tracked'. Coronary artery bypass grafting operations had the lowest 'fast-track' failure and mortality rates. Re-do operations and complex coronary procedures presented a high 'fast-track' failure rate of approximately 20-25%. Low cardiac output, postoperative bleeding and respiratory problems were the most frequent causes for 'fast-track' failure.

CONCLUSIONS

The development of a 'fast-track' unit, supported by a computerised system for information collection and analysis and a pre-admission clinic, has resulted in a substantial improvement of operating numbers and financial income, without adversely affecting the clinical results. This task demanded close collaboration between a dedicated list manager and a designated member of the medical team. Patient selection with appropriate 'fast-track,' criteria may improve further the efficiency of 'fast-track' units in the future.

The association between the on-site availability of cardiac procedures and the utilization of those services for acute myocardial infarction by payer group. The National Registry of Myocardial Infarction 2 Investigators

BACKGROUND

Prior studies have suggested that in-hospital availability may be an important determinant for the use of invasive cardiac services; however, whether this association is influenced by payer status remains unclear.

HYPOTHESIS

The interaction of payer status and the on-site availability of coronary arteriography is associated with increased utilization of this procedure.

METHODS

In-hospital availability and utilization of coronary arteriography was ascertained in 275,046 patients with acute myocardial infarction (AMI) enrolled in the National Registry of Myocardial Infarction 2 from June 1994 to April 1996. Logistic regression analyses were performed to determine the association between the on-site availability of cardiac catheterization at the initial hospital and subsequent utilization of coronary arteriography. Similar analyses were performed within Medicare, Medicaid, Commercial, Health Maintenance Organization (HMO), and Uninsured payer groups.

RESULTS

Patients initially admitted to hospitals having on-site cardiac catheterization facilities were almost twice as likely to receive coronary arteriography as patients admitted to hospitals without such facilities and later transferred out [un-adjusted odds ratio (OR) = 1.69, 95% confidence interval (CI) 1.66-1.73, p < 0.0001; adjusted OR = 2.08, 95% CI 2.01-2.15, p < 0.0001]. Furthermore, this relationship of increased utilization with greater availability was evident within each payer group, but was highest among those with Commercial insurance and lowest among Medicaid recipients: [Commercial insurance (OR = 2.19, 95% CI 2.07-2.31, p < 0.0001); Uninsured (OR = 1.74, 95% CI 1.57-1.92, p < 0.0001); HMO (OR = 1.67, 95% CI 1.54-1.82, p < 0.0001); Medicare 1.60, 95% CI 1.55-1.64, p < 0.0001); Medicaid (1.46, 95% CI 1.29-1.65, p < 0.0001)].

CONCLUSIONS

Our results show a strong association between in-hospital availability and subsequent utilization of invasive cardiac procedures following AMI among all patients, but the strength of these associations varied among payer status.

Effective CPT coding: a multi-disciplinary approach

Billing and reimbursement issues for health care organizations are becoming increasingly complex. There is a great deal at stake in today's environment ranging from inefficiencies, to loss of revenue, to issues of fraud and abuse. By using a multi-disciplinary approach to evaluating the billing and reimbursement process, your organization's ability to avoid the problems associated with filing inaccurate claims will be greatly enhanced.

The algebra of healthcare reform: hospital-physician economic alignment

In summary the tertiary care programs in this nation are trapped in a difficult dilemma. On one side is the ongoing reduction in provider revenue driven by real and powerful market forces. On the other side is a traditional payment system governed by necessary laws that inhibit meaningful re-engineering of tertiary care delivery. If a remedy to this situation cannot be created then it is very likely that all aspects of quality as defined earlier will suffer. It is our hope that by very careful construction of a relationship, with attention to applicable statutes and careful measurement of utilization and quality, a limited business alignment of a hospital and a group of tertiary physicians can be approved in the care of Medicare, Medicaid and all federally funded patients.