Life Flow One
The Solution For Heart Disease
by
Karl Loren
By THOMAS M. BURTON
Staff Reporter of THE WALL STREET JOURNAL
CINCINNATI -- Identifying the best sports teams, consumer products and even chief executives is a matter of measuring performance.
Hospitals are a different case. Those regarded as the best often hold that distinction for much the same reason certain writers and painters do: because of the opinions of the leading critics, endlessly repeated.
Unlike art, though, the quality of an institution's medical care can be measured with some degree of objectivity. So what would happen if it were measured? Would the "best" hospitals retain that reputation -- or be revealed as overrated? Would hospitals regarded as mediocre prove to be such -- or to be worthy performers?
A years-long evaluation of medical performance here in Ohio suggests that between reputation and reality is a patch of ground studded with surprises.
Mortality Rates
The study is narrow, looking only at heart-surgery operations at hospitals in Ohio. It doesn't measure everything that might be thought part of the "quality" of care, focusing mostly on heart-surgery deaths and "adverse outcomes" such as heart attacks, strokes and infections. And the study's complete results aren't available, because Anthem Blue Cross & Blue Shield, the insurer that conducts the study, won't make it public.
But even a limited glimpse is insightful. Where is the best place for Ohioans to undergo heart surgery? People familiar with this state's medical offerings almost certainly would say the Cleveland Clinic. Wealthy patients around the world travel to Cleveland for treatment at the Clinic. And certainly, the Anthem study confirms that the Clinic runs an outstanding coronary unit.
But, according to this gauge, not the best. That distinction is given to a hospital that isn't even situated in Ohio: It sits just across the Ohio River from Cincinnati in a town called Edgewood, Ky. So much for public perception: The hospital, called St. Elizabeth's Medical Center, isn't even perceived by much of the public as operating the best heart-surgery unit in the greater Cincinnati area.
Challenging Reputations
Another surprise: One of the state's most highly regarded coronary units, at Ohio State University Medical Center, ranked among the worst performers in the first Anthem study, released in 1995.
"So many reputations are built on sand," says Derek van Amerongen, medical director for Anthem Blue Cross & Blue Shield, whose Ohio operations are based here in Cincinnati. (The parent insurance company, Anthem Inc., is based in Indianapolis.)
The Anthem study's ramifications go beyond challenging assumptions. It appears to have spurred effective campaigns by Ohio heart-surgery units to improve. Anthem uses the survey to eliminate all but the top 15 such units from its million-member health-maintenance organization in Ohio, the state's largest. That gives them all an incentive to do what it takes to rate well.
Since Anthem introduced this policy in 1995, rates of death and other adverse outcomes have consistently fallen among its members undergoing heart surgery. One example: The rate of heart attack following bypass surgery -- about 2.8% in 1993 -- was a mere 0.9% in 1997.
Turnaround Story
Ohio State University Medical Center helps illustrate the story behind these improvements. After its ouster from the Anthem system in 1995, the Columbus, Ohio, institution reassigned some surgeons, revamped its program and improved its results. And it got back into the Anthem network.
The Anthem experience suggests that a national grading system for hospitals might yield some surprises and ultimately raise the overall level of health care. But the kind of performance information that exists for most products and services is rarely available for medical care, and that isn't likely to change soon. Doctors and hospitals, concerned that any system of measurement will punish providers who treat the sickest patients, tend to resist calls for disclosure of data on outcomes.
Politicians often support that resistance. When Anthem set about duplicating its Ohio program in Kentucky last year, the Kentucky department of insurance balked following protests from the Kentucky Hospital Association and some legislators. The department says it is still considering Anthem's program. One concern: If rural hospitals are deleted from the Anthem network, "people here would have to drive at least an hour and a half" for heart surgery, says State Rep. Jim Gooch Jr. in western Kentucky.
Anthem's response: Those people will stand a better chance of being alive for the drive home.
Of the few efforts under way around the country to measure medical performance, many are the work of HMOs -- a paradox, considering that HMOs are widely perceived as caring more about costs than quality of care.
But Anthem and some other insurers have come to see that demanding quality is an effective way of controlling costs. Since it launched its coronary-services study four years ago, Anthem claims, it has saved about $15 million from negotiating lower rates with network hospitals and several times that amount by avoiding subpar surgical care, which can lead to strokes, heart attacks and infections.
How it Started
Anthem decided about five years ago to conduct a study of heart programs in Ohio because raw statistics led its medical director at the time, Joseph Berman, to question the link between reputation and performance. At any given hospital, he concluded, "there was no correlation between what we paid, the length of stay and the mortality rate."
Of all the services Anthem covers, it chose to study heart procedures because they are so common and so expensive, accounting for 12% of its medical payouts. A simple examination of its existing data showed that hospitals performing fewer than 250 heart surgeries a year generally had worse results than those doing more than that. So Anthem scratched from its network any coronary-services unit performing fewer than 250 operations a year. Of the 31 such heart units serving Ohioans, about 10 fell below that level.
To grade the remaining facilities, it devised a survey seeking about 300 pieces of medical information. It hired a Chicago cardiologist and statistics expert, Michael Pine, to establish a "risk adjustment" formula that would avoid penalizing hospitals for treating especially sick patients.
Many hospitals protested loudly upon receiving the Anthem survey. Besides its implicit questioning of their quality, the survey was hard work, requiring weeks to complete. But no hospital could afford to snub the state's largest HMO. And in any case, every hospital felt confident about its heart-surgery facility.
This made it difficult for Anthem, after tallying the results, to present them to institutions that didn't make the cut. The handful of hospitals it ousted from its coronary-services network included some of the best-regarded in Ohio. Officials at one responded, "Do you know how many articles we had published last year in the New England Journal of Medicine?" says Dr. Berman's assistant, Kimberly Byrwa. (At least one hospital chose not to be in the network for financial reasons.)
Every heart-surgery unit that got a low grade from Anthem believed it was treating the sickest patients, which could cause higher mortality. This belief, Dr. Berman says, was "like Holy Writ. The more people repeated this mantra, the more they believed it."
Ejection from the Anthem network certainly shocked officials at Ohio State. A national magazine, relying partly on reputation, had placed the university on its 1994 list of America's top hospitals for cardiology and open-heart surgery. As an academic medical center, Ohio State also had a thriving regional heart-transplant center and was a leader in the use of heart-assist machines.
Opposing View
"I disagreed strongly with Anthem's study," says David Myerowitz, then chief of cardiothoracic surgery at Ohio State. "Our mortality data weren't much different from other programs at the time, and they got better." Among other things, Dr. Myerowitz criticizes the study for not directly auditing patients' charts to verify information the hospitals submitted.
But others at Ohio State were quite concerned about Anthem's findings. It was their first look at how their program compared with others, and the news wasn't good. The risk-adjusted mortality rate for bypass and heart-valve surgery -- 6.1% in 1993, when Anthem graded hospitals for its 1995 network -- was the worst of any Ohio hospital in the study. Some hospitals had mortality rates below 1%.
Senior hospital officials say that, partly because of concern over such findings, they asked Dr. Myerowitz to resign as chairman of cardiac surgery. He left as chairman in mid-1996. He says it was partly because of a dispute with administrators over the volume of surgery at the hospital. Later, Dr. Myerowitz left the hospital entirely, a departure that he says had nothing to do with the Anthem study.
Hospital administrators say some improvements that have since been made in the department began under Dr. Myerowitz, while others have occurred since his tenure. The university hospital's medical director, Hagop Mekhjian, says it is a "fair conclusion" that bringing in a new chief of cardiothoracic surgery "had a great deal to do with allowing the changes to take place."
Recruiting Elsewhere
The hospital took steps to see that some surgeons who had lackluster results no longer performed heart surgery, and it recruited renowned doctors to revamp the program. One is Robert E. Michler, a prominent surgeon from what was then called Columbia-Presbyterian Medical Center in New York, who became Ohio State's chief of cardiothoracic surgery. Another is Pascal Goldschmidt from Johns Hopkins, now chief of cardiology.
To bring focus to details, the 42-year-old Dr. Michler asks his colleagues to read "Into Thin Air," Jon Krakauer's book about a Mount Everest expedition, for its illustration of how minor errors can ultimately prove disastrous.
Ohio State has turned its results around. When Anthem announced its network for the years 1997-2000, Ohio State made the list. It had achieved a risk-adjusted mortality figure for bypass and heart-valve operations of 2.63%, about the Anthem average. Dr. Michler says last year's raw mortality rate for bypass surgery was 1.48%.
The initial Anthem study sent shock waves of a different sort through St. Elizabeth. Its heart-surgery staff believed its care was good, but nobody expected it to be deemed the best of any serving Ohioans. The ranking evidently wasn't a fluke; St. Elizabeth has been on top in every subsequent Anthem study.
"Their mortality score was so low nobody would believe it at first," recalls Dr. Pine, the Chicago cardiologist Anthem hired to crunch numbers. "They are one of the jewels not known beyond their community."
The Nurses
Three surgeons at St. Elizabeth handle a total of about 750 open-heart cases a year, enough for the procedure to become routine for the doctors and the support staff. But the real secret at St. Elizabeth may be its nursing program. It employs lots of coronary-service nurses, keeps them focused on this specialty and gives them plenty of power.
"At a time when most hospitals have been re-engineering and cutting back on nurses, St. Elizabeth seems to have taken the approach that there is no substitute for a reasonable number of highly trained nurses caring for the patient," Dr. Pine says.
The nurses are free to second-guess even Ray Will, chief of cardiac surgery. "Let's say a nurse were afraid of me," the surgeon muses. "And let's say I had just decided to discharge a patient. Let's say that nurse maybe just has a sense that a patient has gotten sicker." If it weren't for St. Elizabeth's open atmosphere, Dr. Will says, "she might not say anything because she didn't want to make me mad."
It is such subtle factors that can make a difference between living and dying. "Those fringe 10 cases a year can make our numbers look good," says Dr. Will.
Anthem prohibits its member hospitals from marketing or even disclosing the results of the survey. This means that while its patients are protected from making use of the worst-performing heart-surgery units in Ohio, they lack the information to choose from among the best-performing. Anthem's reasoning: Its aim is to improve overall quality, not fuel competitive battles.
The insurer -- its heart study having apparently brought about improvements -- now is considering targeting other specialties, such as joint replacement.
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