JACC: Combining CV outcomes demonstrates better hospital quality
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| Image Source: Chicago Alliance of Community Health Centers |
Tracy Y. Wang, MD, an assistant professor of medicine at the Duke Clinical Research Institute in Durham, N.C., and colleagues compared AMI and HF performance measures in 283 hospitals that participate in the American Heart Association’s Get With The Guidelines (GWTG) program. Their goal was to assess the correlation between the two measures and to evaluate whether hospitals that adhered well to both measures also showed superior patient outcomes.
In an interview with Cardiovascular Business, Wang said the research team wanted to explore the potential advantages of a more global approach to assess quality metrics by looking beyond single disease states and discrete measures to a broader model. “After all, the focus is making sure patients do well overall,” she explained.
The researchers selected AMI and HF performance measures of the Centers for Medicare & Medicaid Services (CMS) and used GWTG data, which the CMS accepts from hospitals to assess performance. The team restricted its sample to hospitals that submitted 10 or more patient records through the GWTG-coronary artery disease program and 10 or more patient records through the GWTG-HF program. Their final sample totaled 283 hospitals and 393,223 patients.
The researchers defined superior adherence as the upper tertile of performance for each set of metrics. They found that 18 percent of the hospitals had superior adherence to both AMI and HF core measures; 16 percent had superior adherence to AMI measures only; 16 percent had superior adherence to HF measures only; and 51 percent had superior adherence to neither measure.
“Our study found that hospitals that performed well in one set of cardiovascular metrics (e.g., AMI care) do not necessarily do well in another set of metrics (e.g., HF care),” the authors wrote. “Yet the centers that excel at both sets of metrics generally perform better than the centers that excel at each alone. Furthermore, these hospitals have lower risk-adjusted mortality for cardiovascular disease patients compared with other hospitals.”
Wang said the researchers were “surprised” to find the AMI and HF measures were only weakly correlated. They speculated that reasons may be tied to varied types of effort, resources and personnel.
Hospitals with superior adherence in both measures were larger than hospitals in the other three groups. Compared with those that had superior adherence to neither measure, they also were more likely to be teaching hospitals, to have participated longer in the GWTG program and treated patients who more frequently were younger, male and white.
The researchers proposed that longer participation in programs, such as GWTG, improves performance because the programs track and provide feedback that informs hospitals. Because the process is iterative, hospitals potentially can identify opportunities for improvement. The authors also speculated that superior hospitals may be better organized and have better coordination of clinical and administrative care protocols.
Importantly, hospitals that had superior adherence to both AMI and HF measures also had lower mortality rates. Wang et al reported an in-hospital mortality rate of 3.3 percent for hospitals with superior adherence to both measures compared with 4.2 percent for hospitals that had superior adherence to none. Adherence to only one measure was not associated with improved mortality, the researchers wrote.
They suggested that more consistent use of care may contribute to lower mortality in hospitals, as well as what they termed better global quality of care. “Risk-adjusted mortality and other outcomes are likely influenced by factors that are not routinely assessed in a registry database, but are closely associated with the overall quality of hospital care,” they wrote.
Specifically, the researchers cited leadership, accountability and investments in health IT among unmeasured but influential factors.
“[W]e postulate that hospitals that are able to provide superior adherence to both AMI and HF measures reflect an optimal hospital culture—that is, resource allocation, activity of quality oversight committees, staffing or other processes—that elevate the global quality of care and outcomes,” they wrote.
They concluded that a global approach may be an effective strategy for improving patient care. Wang added hospitals that incorporate a global approach could serve as models for others. “There are lessons to be learned from these better performing hospitals,” she said.
As limitations to the study, the researchers pointed out that it was observational and therefore could be confounded by unmeasured variables. Data were limited to in-hospital patient data, and because GWTG is voluntary, its members may not accurately represent hospital care across the U.S.