Performance of top-ranked heart care hospitals on evidence-based process measures

BACKGROUND

Despite the increasing availability of evidence-based clinical performance measure data that compares the performances of US hospitals, the general public continues to rely on more popular resources such as the US News & World Report annual publication of "America's Best Hospitals" for information on hospital quality. This study evaluated how well hospitals ranked on the US News & World Report list of top heart and heart surgery hospitals performed on acute myocardial infarction and heart failure measures derived from American College of Cardiology and American Heart Association clinical treatment guidelines.

METHODS AND RESULTS

This study identified 774 hospitals, including 41 of the US News & World Report top 50 heart and heart surgery hospitals. To compare hospitals, 10 rate-based performance measures (6 addressing processes of acute myocardial infarction care and 4 addressing heart failure care), were aggregated into a cardiovascular composite measure. As a group, the US News & World Report hospitals performed statistically better than their peers (mean, 86% versus 83%; P < 0.05). Individually, however, only 23 of the US News & World Report hospitals achieved statistically better-than-average performance compared with the population average, whereas 9 performed significantly worse (P < 0.05). One hundred sixty-seven hospitals in this study routinely implemented evidenced-based heart care > or = 90% of the time.

CONCLUSIONS

A number of the US News & World Report top hospitals fell short in regularly applying evidenced-based care for their heart patients. At the same time, many lesser known hospitals routinely provided cardiovascular care that was consistent with nationally established guidelines.

Using public reports of patient satisfaction for hospital quality improvement

OBJECTIVE

To explore the impact of statewide public reporting of hospital patient satisfaction on hospital quality improvement (QI), using Rhode Island (RI) as a case example.

DATA SOURCE

Primary data collected through semi-structured interviews between September 2002 and January 2003.

STUDY DESIGN

The design is a retrospective study of hospital executives at all 11 general and two specialty hospitals in RI. Respondents were asked about hospital QI activities at several points throughout the public reporting process, as well as about hospital structure and processes to accomplish QI. Qualitative analysis of the interview data proceeded through an iterative process to identify themes and categories in the data.

PRINCIPAL FINDINGS

Data from the standardized statewide patient satisfaction survey process were used by hospitals to identify and target new QI initiatives, evaluate performance, and monitor progress. While all hospitals fully participated in the public reporting process, they varied in the stage of development of their QI activities and adoption of the statewide standardized survey for ongoing monitoring of their QI programs. Most hospitals placed responsibility for QI within each department, with results reported to top management, who were perceived as giving strong support for QI. The external environment facilitated QI efforts.

CONCLUSION

Public reporting of comparative data on patient views can enhance and reinforce QI efforts in hospitals. The participation of key stakeholders facilitated successful implementation of statewide public reporting. This experience in RI offers lessons for other states or regions as they move to public reporting of hospital quality data.

Differences in characteristics of US hematopoietic stem cell transplantation centers by proportion of racial or ethnic minorities

Racial or ethnic minorities with leukemia who receive HLA-identical sibling hematopoietic stem cell transplants (HSCTs) are reported to have worse survival when compared with whites. Characteristics of US HSCT centers according to the proportion of ethnic minorities who undergo transplantation were compared to explore systematic differences among centers; the association with 100-day mortality was evaluated to determine whether center factors may explain the observed discrepant survival among ethnic minorities. One hundred sixteen US transplantation centers that performed HLA-identical sibling transplantations for leukemia were analyzed. We compared physician and health care provider staffing, transplantation unit procedure and resources, and medical center organization according to the volume procedure ratio of ethnic minorities who underwent transplantation and also according to the ratio of Hispanics who underwent transplantation. Centers that performed transplantation in a higher proportion of ethnic minorities were more likely to perform fewer transplantations per year, to have fewer devoted transplant beds, to be in an urban setting, to have a lower physician to patient volume ratio, and to follow up survivors 1 year after transplantation. Centers that performed transplantation in a higher proportion of Hispanics were more likely to perform fewer transplantations per year and to have fewer devoted transplantation beds, were less likely to perform outpatient transplantations, were more likely to be in an urban setting, and were less likely to have posttransplantation immunization protocols. Observed differences in center factors were not associated with 100-day mortality after adjustment for disease severity. Our results suggest that the inferior survival reported in ethnic minorities after HSCT may not be readily explained by center effects.

Patient's perception towards the eye health care system in a tertiary eye care centre in Nepal

This study was performed to determine patient's perceptions towards eye health care systems in a tertiary eye care center in Nepal. Subjects were randomly selected from the outpatient department of Tilganga Eye Centre (TEC), a tertiary eye care center in Kathmandu, Nepal. The study was performed in April 2003 with 54 patients responding to several questions concerning their satisfaction of the eye care process. Over 40 (74.1%) of the respondents expressed overall satisfaction with the service provided by the hospital staff, and 4 (7.4%) were not satisfied. In addition, a total of 40 (74.1%) respondents were dissatisfied with the extended waiting time for eye examinations and other ocular services, while 7 (13.0%) were satisfied. The study shows that the majority of patients who are treated at Tilganga Eye Centre have positive feelings about Tilganga and its service system. Some processes, however, could be altered or improved to augment the overall quality of patient care.

Centers of excellence take tiering to the max

Insurers assert that by designating centers of excellence, they direct patients to the best care. Critics charge the concept is a contracting gimmick and will hurt small hospitals.

[Results of the certification of vascular centers by the German Society for Vascular Surgery]

INTRODUCTION

Advances in conventional vascular surgery, endovascular procedures and conservative treatment require close interdisciplinary cooperation. The term Vascular Centre indicates to patients and referring doctors optimal professional and organisational competence.

METHODS

73 applications by vascular centres for certification were made between June 2002 and December 2005, of which after audit 54 were successful for three years, including one centre each in Austria and Switzerland. 13 centres were not accepted and six are still under consideration. This analysis is based on the data of 52 certified centres in the Federal Republic of Germany.

RESULTS

A mean of 1149 patients were hospitalized in these centres per year (12 % emergency admissions) and 2159 patients per year were treated as outpatients, 60 % with arterial vascular disease. All centres have vascular surgery and radiology department, 10 of the 52 centres cooperate with specialists in private practice to provide an angiology service. A mean of 460 arterial vascular operations and 239 arterial interventional procedures were performed at each centre annually. In addition there were operations for varicose veins (n = 217), shunt operations (n = 58) and major amputations (n = 42). Inpatient or outpatient conservative treatment (for peripheral vascular disease, diabetic foot syndrome, phlebothrombosis or chronic venous insufficiency) was given to a mean of 338 patients annually.

CONCLUSIONS

Certification of interdisciplinary vascular centres provides structural and medical data and the beginnings of comparing such centres. A future task will be standardization of documentation and continuing assessment of the quality of results.

Early risk assessment for viral haemorrhagic fever: experience at the Hospital for Tropical Diseases, London, UK

OBJECTIVES

To implement a policy of systematic screening for viral haemorrhagic fever (VHF) among travellers returning from African countries with fever, commencing at initial clinical contact.

METHODS

A protocol based on UK Advisory Committee on Dangerous Pathogens guidance was developed collaboratively by medical, nursing and laboratory staff. Audit was carried out to quantify resource demands and effects on time to diagnose malaria, the main differential diagnosis.

RESULTS

A protocol is now implemented for all patients presenting to HTD with fever, with clear guidelines for interaction with clinical and laboratory staff at each stage. The protocol required moderate amounts of clinical and laboratory staff time and resulted in some additional hospital admissions. The time to a diagnosis of malaria increased from a median of 90 (range 50-125) min in patients without VHF risk to a median of 140 (range 101-225) min (p=0.0025) in those assessed as at risk.

CONCLUSIONS

Although all acute medical services need to have robust procedures for early detection of patients with serious transmissible conditions, few implement such a policy. Our protocol requires increased human and other resources but has no important impact on the rapidity of diagnosis of malaria, and is now embedded in local practice.

Limited service maximum fuss. Specialty hospital issue has caught the attention of senators as a physician-owned Oregon facility fights for its Medicare status

The battle over specialty hospitals got more bruising last week, with two powerful senators seeking more oversight data, and a hospital that's become a symbol of the controversy fighting for its life. The AMA's William Plested, left, says the problem isn't specialty hospitals, but how hospitals are paid. "The way all payments are figured makes winners and losers," he says, noting for-profits contribute to communities through taxes.

Relation Between Hospital Specialization With Primary Percutaneous Coronary Intervention and Clinical Outcomes in ST-Segment Elevation Myocardial Infarction

Background— Hospitals with primary percutaneous coronary intervention (PPCI) capability may choose to predominately offer PPCI to their patients with ST-segment elevation myocardial infarction (STEMI), or they may selectively offer PPCI or fibrinolytic therapy based on patient and hospital-level factors. Whether a greater level of hospital specialization with PPCI is associated with better quality of care is unknown.

Methods and Results— We analyzed data from the National Registry of Myocardial Infarction-4 to compare in-hospital mortality and times to treatment in STEMI across different levels of hospital specialization with PPCI. We divided 463 hospitals into quartiles of PPCI specialization based on the relative proportion of reperfusion-treated patients who underwent PPCI (≤34.0%, >34.0 to 62.5%, >62.5 to 88.5%, >88.5%). Hierarchical multivariable regression assessed whether PPCI specialization was associated with better outcomes, after adjusting for patient and hospital characteristics, including PPCI volume. We found that greater PPCI specialization was associated with a lower relative risk of in-hospital mortality in patients treated with PPCI (adjusted relative risk comparing the highest and lowest quartiles, 0.64; P =0.006) but not in those treated with fibrinolytic therapy. Compared with patients at hospitals in the lowest quartile of PPCI specialization, adjusted door-to-balloon times in the highest quartile were significantly shorter (99.6 versus 118.3 minutes; P <0.001), and the likelihood of door-to-balloon times exceeding 90 minutes was significantly lower (relative risk, 0.78; P <0.001). Adjusting for PPCI specialization diminished the association between PPCI volume and clinical outcomes.

Conclusions— Greater specialization with PPCI is associated with lower in-hospital mortality and shorter door-to-balloon times in STEMI patients treated with PPCI.

Audit of exracapsular cataract extraction with posterior chamber intraocular lens implantation in a tertiary eye care center in Ethiopia

A retrospective audit of records of 370 eyes of 315 patients for whom extracapsular cataract extraction with posterior chamber intraocular lens implantation (ECCE-PC IOL) was performed between 1998 and 1999 was made to determine postoperative visual outcome and complications. One hundred and ninety three patients were males and one hundred and seventy seven were females making a male to female ratio of 1:0.9. At two months postoperatively 82 (30.4%) of eyes had uncorrected visual acuity of 6/18 or better; while 176 (53.7%) of eyes attained an uncorrected visual acuity between 6/18 and 6/60, and 31 (11.5%) had visual acuity between 3/60 and 6/60. 340 of 358 (94.9%) had a preoperative visual acuity of < 3/60. As a result of the surgery, the percentage of blind eyes dropped from 94.9% to 4.4%. The commonest intra operative and early postoperative complications encountered were posterior capsular tear with vitreous loss (5.7%) and striate keratopathy (11.1%) respectively. Posterior capsular opacity was documented in 17 (4.6%) eyes as a late postoperative complication. Routine biometry, to calculate Intra ocular Lens (IOL) power was not done and this was the major limitation of the study. In conclusion, the study increases awareness of cataract surgery outcomes and provides a feedback to achieve better results both in terms of quality and quantity in cataract surgery. Further study with biometric measurement is recommended.

Problemfeld der Notfallverlegungen beim Schlaganfall

BACKGROUND

Specific stroke subtypes like subarachnoid hemorrhages or malignant brain infarcts require immediate interventions, but treatment options are offered mainly in specialized centers. For this reason, interhospital transfers from primary hospitals need to be done without delay.

METHODS

The telemedic pilot project for integrative stroke care (TEMPiS) connects 2 stroke centers and 12 regional hospitals in Bavaria (Germany). Core elements are the implementation of stroke wards, telemedic consultation and improvement of emergency interhospital transfers. Organization of patient transports is offered by the central telemedic service. During the first 12 months of the continuing project all interhospital transfers initiated by the central telemedic service were prospectively documented. Emergency transports were analysed according to diagnosis, type of transport, distance and time delays.

RESULTS

A total of 252 interhospital transfers were recommended in teleconsultations; finally 221 transports took place. Median total duration of transfers (including the necessary arrangements) was 134 min (interquartile range: 105-219) for intracerebral hemorrhages (N = 58), 138 min (95-157) for subarachnoid hemorrhages (N = 31), 161 min (100-230) for malignant infarcts (N = 22) and 147 min (109-180) for suspected basilar artery occlusion (N = 28). Time from admission in the primary hospital to initiation of interhospital transfer was 135 min (median; interquartile range: 86-172), transport time was 81 min (60-116). Helicopter transport did not save time for transfer distances up to 50 kilometres, compared to transport via ambulance (including assistance of hospital physicians). Transport using a special intensive care vehicle was much more time consuming because of the longer transport preparation time.

CONCLUSION

Emergency transfers of stroke patients are time consuming. This may contribute to additional harm being done to severely ill patients. Faster organization and conduct of transports is required.

Orthopaedic centre achieves excellence

Crowborough, East Sussex-located orthopaedic Centre of Excellence, The Horder Centre has worked to eliminate infections and create an environment where patient comfort, safety and care is never compromised. Jason Rayfield reports.

Is cardiac care better at specialty hospitals?

Patient mortality rates and lengths of stay were comparable for specialty and general hospitals that perform similar volumes of the procedures. Findings were similar when comparing high-volume general hospitals and high-volume specialty hospitals. Other measures of quality (i.e., use of aspirin, beta-blockers, ACE inhibitors) may be more significant.

Patient, provider, and clinic characteristics associated with public STD clinic patient satisfaction

OBJECTIVES

There is a lack of information describing levels of patient satisfaction among patients seeking sexually transmitted diseases (STD) care in a public clinic setting. We sought to identify patient, provider, and clinic characteristics associated with patient satisfaction within public STD clinics.

METHODS

A cross sectional survey with random sampling was conducted among patients attending two public STD clinics. Satisfaction was assessed using questions from validated national surveys. Outcomes for multivariate logistic regression analysis were ratings of overall health care and clinician.

RESULTS

499/605 (82%) patients were enrolled. Patients were mean age 29 years, 51% male, 94% black. Lower rating of clinician technical skills (OR = 15.6 clinic A, OR = 7.9 clinic B) and clinic environment (OR = 3.9 clinic A, OR = 9.6 clinic B) were associated with lower healthcare rating, as was lower rating of television/video in waiting room (OR = 10.2, clinic A) and dysuria (OR = 4.2, clinic B). Higher clinician rating (OR = 0.58, clinic A) and receiving written materials (OR = 0.44, clinic B) were protective of lower healthcare rating. Risks for lower clinician rating at clinic A were greater pain, problems getting care, lower rating of clinician technical skill, and overall health care, while receiving written materials was protective. At clinic B, lower rating of clinician technical skill and clinic environment were risks for lower clinician rating.

CONCLUSIONS

Patient satisfaction was associated with modifiable provider and clinic characteristics. Results from our study indicate a need to examine whether health outcomes of STD management vary by patient satisfaction.

Do the Brain Attack Coalition's criteria for stroke centers improve care for ischemic stroke?

BACKGROUND

In 2000, the Brain Attack Coalition (BAC) recommended 11 major criteria for the establishment of primary stroke centers. The BAC relied heavily on expert opinion because evidence supporting the criteria was sparse.

OBJECTIVE

To assess primary stroke center elements, based on the criteria proposed by the BAC, with a questionnaire at 34 academic medical centers.

METHODS

Patient characteristics and outcomes were collected for all patients (n = 16,853) admitted with ischemic stroke to each hospital from 1999 to 2001. Stroke center elements were evaluated as predictors of treatment with tissue plasminogen activator (tPA) and outcomes after adjustment for patient characteristics.

RESULTS

The in-hospital mortality rate was 6.3% (n = 1,062), and 2.4% (n = 399) of patients received tPA. None of the 11 major stroke center elements was associated with decreased in-hospital mortality or increased frequency of discharge home. However, four elements predicted increased tPA use, including written care protocols, integrated emergency medical services, organized emergency departments, and continuing medical/public education in stroke (each odds ratio [OR] > 2.0, p < 0.05). Use of tPA also tended to be greater at centers with an acute stroke team, a stroke unit, or rapid neuroimaging (each OR > 2.0, p < 0.10). Institutions with a greater number of major stroke center elements used tPA more frequently.

CONCLUSIONS

Of the 11 stroke center elements recommended by the BAC, 7 were associated with increased tPA use. Institutions with a greater number of these seven features used tPA more often, suggesting these key elements may be most important for primary stroke center designation, at least in terms of identifying centers that deliver IV tPA frequently.

The debate over specialty hospitals: how physician-hospital relationships have reached a new fault line over these "focused factories"

Within the last 20 years, the fragile symbiotic relationship between physicians and hospitals has become increasingly strained. Physicians have created new healthcare delivery systems, including a host of for-profit, physician-owned specialty hospitals. Proponents of specialty hospitals argue that they provide high quality facilities and allow for innovative treatments. Opponents, however, contend that such hospitals "cherry pick" patients who otherwise would help to subsidize general hospitals, and point to the various fraud and abuse issues raised by physician-owned specialty hospitals. This Article examines the specialty hospital phenomenon and the arguments for and against such entities. It also analyzes whether an extension of the present federal moratorium on the construction of new physician-owned specialty hospitals is in the best interests of the country's healthcare system. The author concludes that the data are unclear as the overall impact of such hospitals and that they should not be further constrained until when and if the facts are clear.