Nearly two years after its debut, Maryland's online report card on hospital performance appears to be fulfilling a key mission: driving hospitals to improve.
The hospitals, for example, are getting better overall at taking commonsense steps to help patients with heart failure and pneumonia. Evidence includes higher rates of pneumococcal vaccinations, according to the state agency that compiles what is formally called the Maryland Hospital Performance Evaluation Guide.
But as the updated report card showed yesterday, individual hospitals still have lots of room for improvement.
New data collected on care provided to heart attack patients reveal that the state's 47 hospitals don't always administer aspirin - which can reduce the incidence of death - when victims arrive in the emergency room.
Bon Secours Hospital in Baltimore gave aspirin 72 percent of the time, below the state average of 93.6 percent, according to the report card, while Fort Washington Medical Center in Prince George's County did so every time.
"These are the types of things that you would expect a hospital would be doing," said Frank Chase, a consumer representative on the Maryland Health Care Commission committee overseeing the development of the report card, which is available free at http://hospitalguide.mhcc.state.md.us.
The report card now compares hospitals based on how often they complete 15 simple steps: six for heart-attack patients, five for pneumonia patients and four for patients with congestive heart failure.
Also, for the first time, consumers can use the report card to check not only how hospitals stack up against each other in each of the categories, but how much they have improved over time.
Among the most improved is Good Samaritan Hospital in Baltimore, which had been giving congestive heart failure patients full discharge instructions just 14 percent of the time in the second half of 2002. By the first half of 2004, it was doing so 80 percent of the time.
Maryland's hospital guide includes other information to help consumers evaluate hospitals, including how often they cared for patients with particular diagnoses - such as heart failure and shock - and how often patients were readmitted after they were treated.
And it continues to evolve: Officials plan next to add patient satisfaction measures late this year and, later still, information showing rates of infections acquired by patients because of their hospitalization.
But even if a hospital had a perfect record, which none does, it's unclear what consumers could conclude about the overall quality of care at a hospital based on the 15 measures alone, experts said.
"This gives me a little more confidence that hospitals are doing some basic things right," said Joseph Antos, a health policy scholar at the American Enterprise Institute, a conservative Washington think tank. "But the answer to the question I want to know is, 'When the surgical team meets over my chest, is it going to go well?' I suspect none of the measures are really going to answer that."
Consumers, the target audience of the report card, haven't fully embraced it yet. It's viewed by about 5,000 people a month, a fraction of the 664,000 patients admitted annually to hospitals in the state.
Incentive to improve
Despite that, state officials and experts said the report card is achieving the goal of prodding hospitals to improve - if only to avoid the embarrassment of a poor public score.
"One of the benefits of that is it does give each of the hospitals in the state a sense of where they are vs. their competitors, and [that's] incentive for hospital and board leadership to improve," said Carol Cronin, an independent consultant. "That wouldn't happen unless it's public information."
Good Samaritan, for example, raised its scores for discharge instructions by taking four steps. It began requiring everyone involved in heart-patient care - physicians, nutritionists, social workers, nurses - to meet daily to discuss each patient and document care instructions.
It also hired a nurse coordinator to oversee the care of congestive heart failure patients and give them information about their medicines, exercise and care. And it began using two software packages, one of which spits out customized discharge instructions for each patient, and another that contains a checklist that care givers use when discharging a patient.
"It's like a discharge police that makes sure that you have everything going on," said Matthias Goldstein, a physician's assistant who is Good Samaritan's director of cardiovascular services. With the changes in place, he said, "I wouldn't be surprised if we got 100 percent in the future."
Among other hospitals, Bon Secours said it has increased rounds focused on ensuring that patients are getting the proper care, after scoring poorly in numerous categories. Greater Baltimore Medical Center said it has renewed a focus on ensuring that congestive heart failure patients get full discharge instructions, after the latest report card showed the hospital was doing so just 12 percent of the time.
And at LifeBridge Health, which operates Sinai and Northwest hospitals in Baltimore, officials are concentrating on doing a better job of counseling heart failure patients to quit smoking. The report card shows Sinai did so 73 percent of the time during the first half of last year, below the state average of 79 percent.
"The good news is hospitals in Maryland have improved in these measures," said Jean Moody-Williams, the commission's chief of facility quality and performance. But, she said, "They're process measures. So theoretically everyone should perform at 100 percent."
There are now at least 45 Web sites analyzing U.S. hospital performance, with the majority of them focusing on a single state or a region of a state, according to the report Cronin co-authored. While officials involved in Maryland's health-care report card call it among the nation's best, it excludes quality measures such as mortality data.
Hospitals often contend that it's nearly impossible to fairly compare death rates among institutions with varying numbers of extremely ill patients. And smaller hospitals say they often don't have enough deaths in certain categories to make the information useful to disclose.
But the state of Pennsylvania, which has been requiring hospitals to disclose mortality data since the inception of its report card in 1988, has seen hospital mortality rates drop from above the national average to below it as a result, said Joe Martin, spokesman for the Pennsylvania Health Care Cost Containment Council, which publishes that state's report.
"Our council members believe for the most part that what they want to know is the result of treatment," Martin said. But, he said, "We're not negative about process measures. There are many different ways to come at the issue of quality."
As Maryland, Pennsylvania and others improve their health-care quality sites, consumers are using them more.
The Kaiser Family Foundation reports that, in a nationally representative survey taken late last summer, 37 percent of people said they were "very likely" to go online to find health-quality information, up from 28 percent in 2000.
Dr. Albert Wu, a Johns Hopkins internist who studies health-care quality and is on the committee overseeing development of Maryland's report card, said he believes such measures eventually will be used to assess not only hospitals, but also physicians' practices and perhaps individual physicians.
Still, Dr. John R. Saunders Jr., GBMC's chief of staff, suggests patients might want to continue to use other means as well, including checking to see whether doctors are board-certified and asking the opinions of doctors and friends.
"I think that all of us who deal with health-care delivery and trying to measure and assess quality realize it's a very difficult thing to measure," Saunders said. "Some of these statistical items ... probably never will be the entire answer. But they're a help."
The state's latest online hospital report card now measures the rate at which hospitals give heart attack patients:
Aspirin within 24 hours of arriving. Studies have shown that use of aspirin early in the course of a heart attack can save lives.
Beta blocker drugs within 24 hours of arriving. The drugs cause blood vessels around the heart to relax, decreasing the heart's work.
ACE inhibitor drugs to patients when the left ventricle fails to pump the necessary amount of blood to the rest of the body.
Aspirin when they're discharged. When aspirin is used long-term after a heart attack, it can decrease the chance of dying, having another heart attack or having a stroke.
Beta blocker drugs when they're discharged. The continued use of these drugs over the long run can decrease the chances of dying.
Advice or counseling on how to quit smoking. Source: The Maryland Health Care Commission