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Hospitals brace for life-and-death look

The Baltimore Sun

The first online tool for comparing mortality rates among America's hospitals went live yesterday, and the added public scrutiny is expected to inject urgency into hospitals' efforts to improve their performance.

Consumers can now go to a federal Web site to see how their hospitals compare with national averages on the percentage of heart attack and heart failure patients who die within 30 days of admission.

Three of Maryland's hospitals were among only 55 nationally whose mortality rates were better than the norms. They are St. Agnes and Good Samaritan hospitals in Baltimore and Suburban Hospital in Bethesda.

The new report card, displayed on Medicare's Hospital Compare site, is the latest made available to consumers to measure the quality of care and the first to measure mortality at individual hospitals. Its development is likely to prompt hospitals to examine their own procedures.

"Whenever a large organization tries to publish your outcomes, it makes a hospital acutely aware of how to improve," said Dr. Richard Lange, clinical chief of cardiology at Johns Hopkins Hospital.

Health and Human Services Secretary Michael O. Leavitt said Americans increasingly go online for hospital quality data to assess best treatment practices, and "when that many people start comparing the quality and cost of health care, the result can only be better quality and lower cost."

But consumers will find little to distinguish one from the next. That's because Medicare used statistical methods to process data that leave nearly all hospitals' mortality rates lumped together as "no different" from the national average.

In Maryland, 42 of the 45 hospitals studied were ranked "no different" from the national averages. None fell below. In a medical crisis, that could be all consumers need to know.

"If you're having the big heart attack, with crushing chest pain, you're going to go to the nearest hospital for treatment," said Joie Rotz, a nurse and quality management director at Washington County Hospital in Hagerstown.

In that case, she said, the new data suggest "you're probably going to get good care and treatment there. I think that's very comforting."

When people have time to choose, most rely on the preferences of their doctors or the experience of friends and family.

But Leavitt said Hospital Compare had 36 million page-hits last year - about 100,000 a day. And the growing availability of performance data has pushed hospitals to re-examine themselves.

At St. Agnes, Dr. Carlos S. Ince, a cardiologist, linked his hospital's performance to its work with ADHERE, a group of hospitals that track their doctors' adherence to treatment guidelines for heart failure patients.

"There is a huge variation" in the way different doctors treat the same heart issues, Ince said. For instance, "when you're having a heart attack, aspirin is one of the cheapest, most cost-effective interventions. But you would be surprised how many hospitals don't give aspirin when they should."

Using computer prompts and pre-printed order sheets, he said, staff at St. Agnes are continually reminded, for example, to prescribe beta blockers or ACE inhibitors for heart patients. If they don't, they must explain why.

"Sometimes you have to get in their face to make sure they're following the guidelines," said Ince, who is president of the medical staff at St. Agnes. He said the CMS results validate its efforts and "makes us want to work harder to improve outcomes even more."

A 2005 study in the journal Health Affairs found that Wisconsin hospitals whose performance data were made public improved significantly over a two-year period. Those whose ratings were not made public changed little or not at all.

"The motivation was their public image," said lead author Dr. Judith H. Hibbard, a health care policy professor at the University of Oregon.

The new data were posted yesterday on the Hospital Compare Web site (www.hospitalcompare .hhs.gov) by the U.S. Centers for Medicare and Medicaid Services (CMS) and the Hospital Quality Alliance, which represents consumer groups, hospitals, employers, accrediting organizations and federal agencies.

"This is really a collaborative effort ... all of us working together to put good information into the hands of the public, using national standardized measures," said Nancy E. Foster, vice president for quality and patient safety at the American Hospital Association.

New comparative information on hospital pricing was also added yesterday. Patient satisfaction data are coming next year.

Consumers have visited the Medicare site for several years to check hospitals' adherence to medical "best practice" standards for the treatment of heart attack, heart failure, pneumonia and the prevention of post-surgical infections.

Similar information for Maryland hospitals is available online from the Maryland Health Care Commission and the Maryland Hospital Association.

"There is more and more recognition that the public needs and wants information," said Nancy Fiedler, a spokeswoman for the association. The MHA site is expected to acquire and display the new 30-day mortality data in a few weeks.

Those rates, for heart attack and for heart failure, were based on claims data for hundreds of thousands of Medicare patients - all ages 65 or older - between July 2005 and June 2006.

Nationally, 16.4 percent of the heart attack patients in the study had died within 30 days of admission. The hospitals' mortality rates ranged from 10.8 percent to 24 percent.

The national average for patients with heart failure was 11.1 percent. Those mortality rates ranged from 6.7 percent to 17.3 percent.

No individual figures were disclosed. However, The Sun queried each of Maryland's 45 hospitals, and 12 furnished their data.

The mortality rate figures are all "risk adjusted," or processed using statistical tools designed to address past objections from hospital officials. Comparisons, they said, had been unfair.

Some hospitals might have higher mortality rates because an urban location or mix of specialties attracts older, poorer and sicker patients. Similarly, smaller ones might experience mortality rates skewed by quirks in the fewer cases treated.

So, CMS and its partners, including hospitals and consumer groups, developed and agreed on statistical corrections to level the playing field.

But the math embeds each hospital's risk-adjusted mortality rate within a broad range of uncertainty, or "interval estimate." Statisticians say there's a 95 percent chance the true rate lies within that range.

All hospitals whose interval estimates overlapped the average national mortality rate were lumped together as "no different" from the national average. That lump includes more than 98 percent of hospitals.

"We're being very conservative," said Herb Kuhn, acting deputy administrator for CMS. "We're not trying to embarrass hospitals."

"You will see hospitals in the middle category that probably should be in the worst category," he said. "But we thought this was the best way to go the first time out."

Future versions will be more refined, he said, providing more detailed comparisons.

Of the 4,477 hospitals included in the current findings for heart attack mortality, only 17 were found to have performed better than the national average, while seven performed worse.

Likewise, of the 4,807 hospitals included in the heart failure data, only 38 performed better than the national average. Thirty-five performed worse.

Dr. Lange, at Hopkins, said the methodology still leaves the vast majority of hospitals statistically indistinguishable. "But this is the first iteration. I think the methodology will become refined. I just don't think it's there yet," he said.

Dr. Sidney M. Wolfe, director of the Public Citizen Health Research Group, said that by using a statistical standard that puts almost all hospitals into a "great unwashed middle" category, the CMS is "depriving most people in the country of information that could be useful."

Wolfe said Medicare should use a less stringent standard that would identify hundreds of hospitals, rather than dozens, as better or worse than average.

Individual hospitals are also poring over the their own detailed, patient-level data from the CMS report to improve.

"We're going to review all of these cases," said Barbara Epke, a LifeBridge Health vice president based at Sinai Hospital. The goal is to see "if there are facts to learn, either about the [patient care] processes that occurred, or anything to learn about the hospital stay itself ... [or] about discharge planning."

Hospitals received much more detailed data than was posted and are expected to compare notes.

"When we find out who those one or two hospitals are [that bested the national averages] we're all going to be calling them up to see if there is anything we can copy," said Dr. Robert Brooks, vice president for medical affairs at Washington County Hospital.

frank.roylance@baltsun.com

Sun reporter William Salganik contributed to this article.

Hospitals examined

This list of Maryland hospitals shows total admissions for heart attack and heart failure, and the percentage of patients who died within 30 days of their admission with those conditions from July 2005 through June 2006. Except where noted by asterisks, all scores fell within statistically significant range of the national average. That means there is no meaningful statistical distinction among them.

Total Heart attack Heart failure

Hospital admissions death rate death rate

National average NA 16.4 11.1

Arundel Med. Center 286 14.6 11.8

Atlantic General 104 16.3 10.0

Bayview 297 17.0 12.2

Franklin Square 437 16.6 9.9

Greater Balt. Med. Ctr. 240 15.2 10.6

Johns Hopkins 249 16.5 9.3

Montgomery General 217 15.6 10.6

Northwest 393 14.1 9.6

Sinai 362 15.6 10.7

St. Agnes 416 13.5 *7.8

University of Maryland 152 18.0 10.8

Washington County 286 17.0 10.3

*Statistically lower (better) than national average Source: Centers for Medicare and Medicaid Services, and hospitals responding to a Sun request for data through the Maryland Hospital Association. Not all hospitals responded. The mortality rates are adjusted to reflect differences in overall health risks among the hospitals' populations.

Quality Care

For heart attacks

Aspirin within 24 hours

Aspirin at discharge

An ACE inhibitor (for left ventricular systolic dysfunction)

A beta blocker to relax the blood vessels

Advice for smokers on how to stop smoking For heart failure

Tests on the left ventricle of the heart

An ACE inhibitor

Instructions on how to care for self at home

For smokers, advice on how to stop smoking [Source: Maryland Health Care Commission]

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