Academic medical center, community hospital partner to market center of excellence

Northwest Hospital in Seattle and the University of Washington Medical Center both had strong cardiology centers. Northwest, however, needed to build its cardiac surgery services, so it entered into partnership with the university to create a new center of excellence in the highly competitive Seattle area.

A community hospital-based congestive heart failure program: impact on length of stay, admission and readmission rates, and cost

OBJECTIVE

To do an analysis of patients with a primary diagnosis of congestive heart failure at discharge before (n = 407) and after (n = 347) the implementation of a comprehensive inpatient and outpatient congestive heart failure program consistent with the guidelines of the Agency for Health Care Policy and Research.

STUDY DESIGN

A retrospective analysis of the impact of the congestive heart failure program on length of stay, admission and readmission rates, and costs to both patient and provider. The program, which used a multidisciplinary team approach, included an intensive education program focusing on diet, compliance, and symptom recognition, as well as the use of outpatient infusions. It also incorporated aggressive pharmacologic treatment for patients with advanced congestive heart failure.

RESULTS

Our analysis revealed significant decreases in length of stay, admission and readmission rates, and costs to the patient and provider (P < or = .05). The mean cost per admission decreased 17% ($1118), and a substantial 77% ($718,468) net reduction in nonreimbursed (lost) hospital revenue was noted.

CONCLUSION

A multidisciplinary, comprehensive congestive heart failure program can improve patient care in a community-hospital setting while significantly reducing costs to both the patient and the institution.

Tracking key clinical data gets to the heart of program's goal: quality, cost effective care

Using data to demonstrate program's strong selling points: better care at lower costs. Vanderbilt University Medical Center's heart failure program tracks patient clinical data, as well as data on hospitalization rates and satisfaction of the population as a whole. The program's success, as well as its wealth of data on patients' severity of illness, should provide an edge in negotiations with managed care companies.

Evaluating and improving the delivery of heart care: the University of Michigan experience

With increasing pressure to curb escalating costs in medical care, there is particular emphasis on the delivery of cardiovascular services, which account for a substantial portion of the current healthcare dollar spent in the United States. A variety of tools were used to improve performance at the University of Michigan Health System, one of the oldest university-affiliated hospitals in the United States. The tools included initiatives to understand outcomes after coronary bypass operations and coronary angioplasty through use of proper risk-adjusted models. Critical pathways and guidelines were implemented to streamline care and improve quality in interventional cardiology, management of myocardial infarction, and preoperative assessment of patients undergoing vascular operations. Strategies to curb unnecessary costs included competitive bidding of vendors for expensive cardiac commodities, pharmacy cost reductions, and changes in nursing staff. Methods were instituted to improve guest services and partnerships with the community in disease prevention and health promotion.

[The "Heart Area" of Juan Canalejo Hospital Complex. A new approach to clinical management]

The present work describes the process by which the pilot project of clinical management of the Hospital Complex Juan Canalejo, designated as "Heart Area", was implemented. In the first section, the needs and reasons that led to the undertaking of this project are explained. The project's objectives and operative strategies are listed. In the Material and Methods section, three basic aspects of the "Heart Area" are described: selection criteria of the "Area", its structure and function, and its foundation and development. In the Results section, we compare the activity undertaken in the "Area" to the situation present prior to its implementation, in relation to quality and costs. Finally, in the Conclusions, we comment on the important implications that our project can have within the Hospital Complex Juan Canalejo as well as in the health care field in general.

[The Institute of Cardiovascular Diseases. The redesigning project of Cardiological and Surgical Services of the Hospital Clinic of Barcelona]

Changes in health systems are determining new hospital organization forms. The patient focused hospital suppose a new radical design of hospital processes from the patient's viewpoint. This paper defines the re-engineering process of the Cardiology and Cardiovascular Surgery Services of the Hospital Clínic of Barcelona in order to develop and Institute. The change consists fundamentally in a reorganization of the direction organs, creating a staff commission and director. The chief nursing and chief management report to the director. Also, a patients admission and management unit, that manage the beds infrastructure of both services has been developed. The first year results show a reduction of the length of stay and an increase in the in-hospital and external activity.

The making of a multipurpose, OR-ready, angiography/interventional cath lab suite

The field of clinical cardiology is now poised to benefit from recent technological advances. Potential for expanding services, increasing productivity, and controlling costs is now awaiting the clinical cardiology. At the same time, certain treatment therapies once addressed exclusively through surgery are being replaced by less invasive procedures performed by interventional cardiologists and radiologists as well as surgeons.

The evolving costs of intracoronary stents

BACKGROUND

As stenting practice has evolved to include greater numbers of stents and adjunctive balloon catheters per case, concern has focused on the increasing costs of equipment for the delivery of stents.

METHODS AND RESULTS

To evaluate temporal changes in costs of intracoronary stenting, we examined total costs, catheterization laboratory equipment costs, equipment utilization, and nonlaboratory hospital costs for stent cases for two time periods: Period I (n = 46; 3 months in 1995 involving routine warfarin anticoagulation) and Period II (n = 129; 4 months during which warfarin was being abandoned). Overall costs declined from Period I ($11,293+/-$7672) to Period II ($9819+/-$3636) (p = 0.074). Catheterization laboratory equipment expenditures rose (Period I, $3823+/-$1394 vs Period II, $4278+/-$1533), whereas noncatheterization laboratory hospital costs declined significantly (Period I, $7281+/-$7179 vs Period II, $5560+/-$3420). The difference in costs was most notable when taking into account the deletion of warfarin anticoagulation. Costs declined by $2428 for patients in Period II in whom warfarin was not prescribed (p < 0.05 vs patients in Period I).

CONCLUSIONS

We conclude that despite the increasing costs for equipment of stent cases, our overall costs of providing stents declined as warfarin anticoagulation was abandoned.

Cardiovascular physiology as a basis for clinical and financial outcomes

This article examines a test program that requires documentation of clinical outcomes before reimbursement will be issued. The battle between financial responsibility and clinical success at any cost is being driven by many influences, and health care professionals are in the middle.

Cost of heart failure to the healthcare system

From an economic, mortality, and functional standpoint, heart failure is clearly a disease that needs to be targeted. We can develop a model for heart failure to determine the impact that specific management strategies will have on the overall cost to the system, which by itself can tell us some interesting things because we're currently spending twice as much on transplantation as on digoxin therapy. We can then use this model to assess the impact of different strategies, such as greater use of angiotensin-converting enzyme (ACE) inhibitors or digoxin therapy.

Influence of payor on use of invasive cardiac procedures and patient outcome after myocardial infarction in the United States. Participants in the National Registry of Myocardial Infarction

OBJECTIVES

We sought to determine the influence of payor status on the use and appropriateness of cardiac procedures.

BACKGROUND

The use of invasive procedures affects the cost of cardiovascular care and may be influenced by payor status.

METHODS

We compared treatment and outcomes of myocardial infarction among four payor groups: fee for service (FFS), health maintenance organization (HMO), Medicaid and uninsured. Multivariate comparison was performed on the use of invasive cardiac procedures, length of hospital stay and in-hospital mortality in 17,600 patients <65 years old enrolled in the National Registry of Myocardial Infarction from June 1994 to October 1995. To determine the appropriateness of coronary angiography, we compared its use in patients at low and high risk for cardiac events.

RESULTS

Angiography was performed in 86% of FFS, 80% of HMO, 61% of Medicaid and 75% of uninsured patients. FFS patients were more likely to undergo angiography than HMO (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13 to 1.42), Medicaid (OR 2.43, 95% CI 2.11 to 2.81) and uninsured patients (OR 1.99, 95% CI 1.76 to 2.25). Similar patterns for the use of coronary revascularization were found. Among those at low risk, FFS patients were as likely to undergo angiography as HMO patients but more likely than Medicaid and uninsured patients. For those at high risk, FFS patients were more likely to undergo angiography than patients in other payor groups. Adjusted mean length of stay (7.3 days) was similar among all payor groups, but adjusted mortality was higher in the Medicaid group (Medicaid vs. FFS: OR 1.55, 95% CI 1.19 to 2.01).

CONCLUSIONS

Payor status is associated with the use and appropriateness of invasive cardiac procedures but not length of hospital stay after myocardial infarction. The higher in-hospital mortality in the Medicaid cohort merits further study.

Cost of cardiac care in the three years after coronary catheterization in a contained care system: critical determinants and implications

OBJECTIVES

We sought to determine the clinical, angiographic, treatment and outcome correlates of the intermediate-term cost of caring for patients with suspected coronary artery disease (CAD).

BACKGROUND

To adequately predict medical costs and to compare different treatment and cost reduction strategies, the determinants of cost must be understood. However, little is known about the correlates of costs of treatment of CAD in heterogeneous patient populations that typify clinical practice.

METHODS

From a consecutive series of 781 patients undergoing cardiac catheterization in 1992 to 1994, we analyzed 44 variables as potential correlates of total (direct and indirect) in-hospital, 12- and 36-month cardiac costs.

RESULTS

Mean (+/-SD) patient age was 65+/-10 years; 71% were men, and 45% had multiple vessel disease. The initial treatment strategy was medical therapy alone in 47% of patients, percutaneous intervention (PI) in 30% and coronary artery bypass graft surgery (CABG) in 24%. The 36-month survival and event-free (death, infarction, CABG, PI) survival rates were 89.6+/-0.2% and 68.4+/-0.4%, respectively. Median hospital and 36-month costs were $8,301 and $28,054, respectively, but the interquartile ranges for both were wide and skewed. Models for log(e) costs were superior to those for actual costs. The variances accounted for by the all-inclusive models of in-hospital, 12- and 36-month costs were 57%, 60% and 71%, respectively. Baseline cardiac variables accounted for 38% of the explained in-hospital costs, whereas in-hospital treatment and complication variables accounted for 53% of the actual costs. Noncardiac variables accounted for only 9% of the explained costs. Over time, complications (e.g., late hospital admission, PI, CABG) and drug use to prevent complications of heart transplantation became more important, but many baseline cardiac variables retained their importance.

CONCLUSIONS

1) Variables readily available from a comprehensive cardiovascular database explained 57% to 71% of cardiac costs from a hospital perspective over 3 years of care; 2) the initial revascularization strategy was a key determinant of in-hospital costs, but over 3 years, the initial treatment become somewhat less important, and late complications became more important determinants of costs.

Evolution of a cardiovascular information system

The competitive nature of our evolving health care system mandates a concomitant increase in the level of sophistication of the cardiovascular information system. The new paradigms in health care also mandate a re-engineering of the process of data collection and analysis. This paper deals with a variety of hardware, software, and human issues encountered at our institution. Topics covered include implementation of service line management, utilization of an interdisciplinary medical informatics model, database conversion, and application development. Special attention will be paid to the development of a system which is a comprehensive information system for clinical and financial management of the cardiovascular patient, not just a quality-of-care database.

Patterns and costs of hospital care for coronary heart disease related and not related to diabetes

OBJECTIVE

To describe the epidemiology and costs of coronary heart disease (CHD) requiring hospital admission, with particular reference to diabetes.

SETTING

The former South Glamorgan Health Authority, South Wales.

METHODS

Routine hospital activity data were record linked and all diabetic and non-diabetic individuals over a four year period (1991-95) were identified. A cost weight was included for each admission based on diagnosis related groups.

RESULTS

There were 10,214 patients admitted with a primary diagnostic code for CHD, representing an incidence of 6.3 per 1000 per annum. Including all CHD and non-CHD admissions, these individuals were responsible for 17% of acute inpatient activity. Men had a consistently higher age specific prevalence of CHD than women. The age adjusted relative risk of CHD for patients with diabetes compared with those without was 4.1 for men and 5.5 for women. Patients with diabetes accounted for 16.9% of CHD related admissions and had a fourfold increased probability of undergoing a cardiac procedure. The total cost of CHD was estimated to be 6% of NHS revenue at 1994-95 pay and prices. Patients with diabetes were responsible for 16% of this expenditure. This translated to an estimated NHS acute hospital expenditure for CHD of 1.1 billion pounds per year at 1994-95 pay and prices.

CONCLUSIONS

CHD was responsible for a larger proportion of NHS expenditure than had previously been reported. Nearly one in five acute hospital admissions were for patients whose condition included cardiac problems. The relation between diabetes and CHD was particularly evident, and may offer opportunities for disease prevention.

Long-term outcome in acute myocardial infarction patients admitted to hospitals with and without on-site cardiac catheterization facilities. MITI Investigators. Myocardial Infarction Triage and Intervention

BACKGROUND

Previous studies have documented the strong association between availability of on-site cardiac catheterization facilities and increased use of coronary angiography in patients with acute myocardial infarction (AMI). Although these studies have shown little influence of the availability of catheterization labs on hospital mortality, no long-term follow-up has been reported.

METHODS AND RESULTS

From a cohort of 12,331 AMI patients admitted to 19 Seattle area hospitals, we compared long-term outcome in 7985 patients admitted to hospitals with and 4346 patients admitted to hospitals without on-site catheterization labs. During the index hospitalization, patients admitted to hospitals with on-site catheterization were more likely to undergo coronary angiography (67.1% versus 39.3%, P<.0001), coronary angioplasty (32.5% versus 13.2%, P<.0001), or coronary bypass surgery (12.5% versus 9.5%, P<.0001). At 3-year follow-up, patients admitted to hospitals with on-site catheterization labs were more likely to undergo postdischarge angiography (19.2% versus 15.2%, P=.0001) and coronary angioplasty (11.6% versus 8.2%, P<.0001). This was associated with approximately $2500.00 per patient in higher cumulative costs. Despite this higher rate of procedure use, there was no association between admission to a hospital with on-site catheterization facilities and lower long-term mortality (multivariate hazard ratio, 1.0; 95% CI, 0.93 to 1.1., the hazard being associated with admission to hospitals with on-site catheterization facilities).

CONCLUSIONS

In an urban area with unconstrained patient transfer mechanisms and high overall cardiac procedure use rates, AMI patients admitted to hospitals without on-site catheterization facilities were managed with fewer procedures during hospitalization and follow-up. This more conservative treatment approach was not associated with any observed increase in long-term mortality.

Information systems requirements for tracking cardiovascular costs and outcomes

Despite much publicity, formal tracking of cardiovascular costs and outcomes remains a poorly understood and applied topic. Proper use of information systems is the primary way in which business models can be successfully applied to healthcare processes to achieve superior outcomes. Successful systems must meet certain conceptual, organizational, and implementation requirements.

Pursuing clinical and operational improvement in an academic medical center

BACKGROUND

An academic medical center in an increasingly competitive market, the University of California-Davis Medical Center in Sacramento started working with a consulting firm in 1995 to reduce overall operational costs and costs for the clinical processes involved in treating patients with specific conditions.

ESTABLISHING THE TEAMS

Twelve operational efficiency (OE) teams and five clinical teams were commissioned, with a combined total of nearly one-half of the target cost reduction. The second wave of six clinical teams was simultaneously initiated in late spring 1996.

THE IMPROVEMENT METHOD

The quality improvement process for clinical improvement teams included the review and inquiry method, which enables many pilot experiments to be conducted in parallel by work groups and coordinated by the main task team.

RESULTS AND CASE STUDIES

Within six weeks of launching, the 12 OE teams achieved their goals and identified savings opportunities of more than $27 million. One OE team, medical records, had set a goal of $514,000 in cost reduction for a three-year period and achieved the first-year goal of $190,000. For a clinical team on interventional cardiology, the clinical benchmark data revealed that the cost per case of providing cardiac catheterization was greater than for all three benchmark groups. These patients, including 270 patients per year, showed a possible savings through process improvement of nearly $1.4 million. From January 1996 through March 1997, the rate of occurrence of complications decreased from 5.5% to 3%.

EPILOGUE

Physicians gradually accepted more responsibility and accountability for controlling and reducing costs, while maintaining their traditional role as advocates for improved patient care.

Continuous quality improvement decreases length of stay and adverse events: a case study in an interventional cardiology program

A study was performed to assess the effectiveness of continuous quality improvement in achieving a better quality of care for patients undergoing coronary interventions. Increasing utilization of new coronary interventional devices has incurred a higher incidence of complications, prolonged hospital stay, and related costs. Using a clinical information system, we adopted continuous quality improvement to control the incidence of complications and postprocedural length of stay. Multiple regression analysis and a matched case-control study were performed to detect complications related to postprocedural length of stay and their causes among 342 patients. The results led to the modification of the postprocedural heparin anticoagulation protocol, which was followed by the introduction of a ticlopidine-based poststent anticoagulation regimen. Two sequential groups of patients (n = 261, n = 266) were selected to compare postprocedural length of stay and frequency of complications with those for the first group. Adjustments were made for patients and procedural characteristics through stratification and multiple regression methods. Blood transfusion was the most important predictor of prolonged hospital stay (partial R2 = 0.26, P < 0.01). A high level of postprocedural anticoagulation and intracoronary stent use were significantly associated with blood transfusion (P = 0.01, P = 0.02, respectively). The comparison among the three groups showed that heparin protocol change reduced only postprocedural length of stay (P < 0.001) for patients without stents, whereas the stent change in anticoagulation protocol significantly reduced both transfusion and hospital stay for patients with stents (P < 0.001, P < 0.05, respectively). Continuous quality improvement based on clinical information is promising to control both complications and hospital costs. Physician involvement is necessary throughout the process.