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Resources abound for cardiologists who want clinical benchmarking data, but according to a new study, nearly half of the hospital administrators responding have to look hard for accurate, real-time, national and regional benchmarks that integrate cost and clinical quality. That’s one of the key messages that came out of Trends in Cardiovascular Programs: A National Management Benchmarking Study. Released at the end of 2000, the study looked at more than 140 data points from nearly 100 hospitals ranging from 10 to more than 800 beds.
According to Susan Heck, RRT, MS, a senior consultant with Health Care Visions, the Pittsburgh consulting firm that wrote the report, what they have created isn’t necessarily better than what is already out there. "All benchmarks have a purpose. For instance, the Society of Thoracic Surgeons is clinically focused. But this gives a broader brush of organizational, management, physician practice, and credentialing issues. This is bigger than a simple clinical focus."
A colleague, Susan Heilman, RN, MPM, another senior consultant, adds that the focus on management issues is what differentiates these data. "What we have been told by clients is that getting benchmarks relevant to daily practice can be elusive," she says. "If you are looking to make a case to medical staff, finding that kind of information, short of doing your own survey, can be hard. This is a quick answer for folks trying to address certain issues."
According to the survey, there are more than a half-dozen places where the 96 respondents get cardiovascular benchmarking data.
The American College of Cardiology data were used by 57% of the respondents, the Society of Thoracic Surgeons by 45%, and a private consulting firm by 24%. Hospital data (24%), corporate organizational data (16%), payer data (14%), cath lab suppliers (12%), and cardiovascular vendor client database information (9%) rounded out the sources most commonly used. Other sources of information include: the National Registry of Myocardial Infarction, state and national databases, the Society for Cardiac Angiography and Intervention, the Center for Healthcare Industry Performance Studies, MECON, the Maryland Hospital Association, HBS International, literature reviews, and VHA.
Despite complaints about lack of data, only 22% of the institutions questioned said they have comprehensive cardiovascular information systems. Those who did used Marquette, Axis, Clinical Reference Systems, Heartbase, Witt, and STS Dendrite, or they had an internally developed system. The data in which respondents are interested range from volumes and productivity to profitability by payer. (For a list of regularly generated management reports, see Table 1.)
Table 1: Regular Reports Generated for Cardiovascular Programs
|Profit and loss statements||66%|
|Cost per case||43%|
|MD report cards||22%|
|Profitability by payer||22%|
Note: Percentages indicate percent of respondents.
Among other key findings of the survey:
• Most hospitals either already have or plan to offer cardiovascular services as a comprehensive product line, heart institute, or heart center. Those that have done so already have had volume growth in this highly lucrative area, while others experienced no growth.
• Given escalating costs, utilization statistics in the catheterization lab were of high significance. The direct cost and utilization rates of devices such as balloons and stents are factors that have a great implication on the profitability of cardiac service. Those with high volumes of patients use only 1.28 stents per case, while those doing fewer than 500 cases per year use nearly 1.5 stents per case. (For more on average numbers of various procedures by bed class, see Tables 2-4.)
|Source for all charts in this story: Health Care Visions, Pittsburgh.|
• The introduction of adjunct drug therapy in the treatment of chest pain and angioplasty patients has improved clinical outcomes, but at a significant cost. Drugs such as Reopro, Integrelin, and Aggrastat are utilized in coronary interventions about half the time, adding significantly to the direct costs of care.
• Open-heart surgery is under intense market scrutiny because of publicly available data about outcomes and quality of care. Best practices outlined in the study indicate that 68% of respondents use less than two units of packed red blood cells per open-heart surgery case. A quarter of the participants in the survey reported that patients are extubated less than five hours after surgery.
• Delays resulting in increased length of stay are common for 79% of the facilities. Part of the delay is associated with patient transfers between ICU and telemetry levels of care. A one-stop postoperative model of care delivery can alleviate those delays.
• Implanting pacemakers in a cath lab can reduce costs significantly. On average, 73% of pacemaker procedures still are performed in a more expensive traditional OR setting.
One of the biggest issues the study uncovered was difficulties with credentialing and medical staffing. The study found 62% of respondents use radiologists exclusively to interpret the nuclear medicine portion of a stress test, and 22% of those are considering plans to change the assignment of interpretation responsibilities in the next two years. Cardiologists are likely to get this responsibility. The trend toward cardiologists performing peripheral angiography and nuclear interpretation needs to be considered in market share projections, medical staff relations, facility plans, equipment selection, and credentialing requirements, the study notes.
Heilman says these issues are going to continue to perplex administrators. "Administrators are getting caught up in these turf struggles."
Heck adds that the effectiveness of a cardiology program will be determined in part by how effective a hospital is at finding compromise with staff. "If vascular surgeons say they don’t want cardiologists working on peripheral vascular procedures, there may be a loss of volume to a facility that has found a way of dealing with the issue," Heck says. "Cardiologists are the gatekeepers. Bar them from one hospital, and they’ll take their patients to another."
Length of stay is another issue that the survey showed continues to plague hospitals, Heck says. "How do you progress the patient, maintain quality of care, have good outcomes, and get positive patient and family satisfaction?" she asks. "So many issues play into this. Take staffing: There are a wide number of methods and combinations of personnel used to take care of patients. With worker shortages, it’s critical how the issue is addressed."
The survey found that retaining staff was either somewhat or very difficult for many institutions. A quarter found if very difficult to retain cardiovascular ICU nurses, and 61% found it somewhat hard. Cardiovascular OR staff was hard to retain for 77% of the respondents. "By and large, the study validated issues that we thought were important," Heck says. "We had ideas, through client anecdotes, that these were the important issues."
The dilemma in the future is for hospital executives to understand the bottom line — both financially and regarding quality of care. "There is a critical mass you have to have," Heck says. "You have to have an infrastructure, and an expensive one, to support equipment and personnel. You need to meet a threshold volume to make money doing this service. You can have loss leaders in your hospital profile, but this is one service that should drive the bottom line. Open-heart surgery provides a lot of dollars."
The bottom line message is grow it or get out, she says. And for nearly 40% of the respondents, it is a message they will have to concentrate on hard. Those institutions say they haven’t taken the necessary steps to maximize profitability within the cardiovascular service line. Forty-seven percent of the nonopen-heart programs didn’t have cost reduction initiatives in place, and a small but significant number of organizations haven’t even established standardized care pathways for diagnoses such as congestive heart failure and acute myocardial infarction.
Cardiovascular reimbursement rates are lucrative compared to the rest of the acute care patient mix, the study concludes. That means hospitals have to be vigilant in controlling costs. And cardiovascular medical and surgical specialties should be integrated in the development of a comprehensive delivery model. The path to this is administrative and medical staff restructuring and medical staff participation in such projects. "Medical staff collaboration is evident in sophisticated cardiovascular service delivery models," the report states. "Involving physicians in administrative decision making prompts rapid adoption of policies and facilitates the change process."
[For more information, contact:
• Susan Heck, RRT, MS, Senior Consultant, Health Care Visions, 3283 Babcock Blvd., Pittsburgh, PA 15237. Telephone: (412) 364-3770.
• Susan Heilman, RN, MPM, Senior Consultant, Health Care Visions. Telephone: (412) 364-3770.
For more on the study or to order a copy, call (800) 837-5800, ext. 352.]