ACC: Cards need to embrace quality metrics (Part Two)
NEW ORLEANS—The cardiology profession seems to suffer from a collective case of magical thinking, offered Charles McKay, MD, of the University of California - Los Angeles. Symptoms include a sense that quality measurement is not real, an insistence that decision support is unnecessary and a belief that hospitals don’t care about quality. Researchers shared data from five outcome studies that addressed these sacred cows, during a presentation at the annual meeting of the American College of Cardiology. (The final two studies are profiled below. Read CVB Daily on April 7 for the first three.)
McKay confirmed the tremendous variations in performance and outcomes and emphasized that the specialty needs to address the situation. “Hospitals are going to be measured on administrative data [quality]. Cardiologists need to take responsibility for clinical data.”
Heart failure outcomes vary
It’s no secret that management of patients with acute heart failure is a major healthcare challenge; short-term mortality rates and readmissions represent significant concerns.
Consider the U.S., which spent $39 million on acute heart failure patients in 2010; 75 percent of spending was related to hospital admissions, shared Ahmed Selim, MD, of the Albert Einstein College of Medicine in New York City.
A recent European study showed 24 percent of acute heart failure patients are readmitted within six weeks, continued Selim.
Selim and colleagues hypothesized that among patients admitted for congestive heart failure, those admitted and treated by a specialized cardiology service will have better outcomes than those treated by a general medicine service.
The researchers searched EMRs of patients admitted for heart failure between 1999 to 2009 at Montefiore Medical Center (New York City) and divided patients into two groups: those served by specialized clinicians and those served by internal medicine physicians.
According to the researchers, 2,071 patients were in the specialist group and 6,874 were in the internal medicine group. They examined 60-day readmissions and mortality outcomes and also considered rates for beta-blockers, ACE inhibitors, spironolactone and ICDs and found “clearly significant differences’’ between the groups. “There was inadequate adherence to evidence-based congestive heart failure guidelines by non-specialized physicians,” reported Selim.
Sixty-day mortality and readmissions were higher for the internal medicine patients. Patients on the internal medicine service had a 60-day mortality of 9.7 percent, while the specialist cohort had a rate of 6.2 percent. Readmissions were 25.9 percent for internal medicine patients and 21.5 for the specialized patients.
However, length of stay was higher in the specialist cohort with a mean length of stay of 7.7 days, just shy of a day more than the internal medicine group, which had a mean length of stay of 6.8 days.
“The take home message,” stressed Selim, “is that cardiologists and congestive heart failure services need to be more involved in the management of patients admitted for decompensated heart failure to ensure adequate implementation of guidelines in their institution.”
Variability in AMI readmissions and mortality
“A rising tide does not lift all boats,” observed Vivek Kulkarni, a second-year medical student at Yale University School of Medicine in New Haven. Kulkarni used the analogy in reference to suspected variability among hospitals in terms of acute MI (AMI) readmissions and mortality.
Previous studies have reported improvements in AMI mortality rates from 1995 to 2006. Kulkarni and colleagues sought to determine how individual hospitals have experienced changes in AMI mortality and to characterize patterns of hospital-specific changes in AMI mortality.
They focused on two time periods: January 1995 to December 1998 and January 2006 to December 2008 and employed changes in the risk-standardized mortality rate (RSMR) as the main outcome.
The researchers examined data from 2,643 hospitals and found that the mean RSMR was 18.5 percent in the first time period and 13.9 percent in the latter.
“In general, we observed improvement in RSMR,” noted Kulkarni, who continued, “Although the majority of hospitals have gotten better, 4.4 percent of hospitals are worsening.”
The researchers also found a strong association between worse baseline RSMR and increased improvement in RSMR.
The next step, confided Kulkarni, is to determine which characteristics correlate with improvements and worsening in RSMR, with the ultimate goal of developing an RSMR model.
McKay confirmed the tremendous variations in performance and outcomes and emphasized that the specialty needs to address the situation. “Hospitals are going to be measured on administrative data [quality]. Cardiologists need to take responsibility for clinical data.”
Heart failure outcomes vary
It’s no secret that management of patients with acute heart failure is a major healthcare challenge; short-term mortality rates and readmissions represent significant concerns.
Consider the U.S., which spent $39 million on acute heart failure patients in 2010; 75 percent of spending was related to hospital admissions, shared Ahmed Selim, MD, of the Albert Einstein College of Medicine in New York City.
A recent European study showed 24 percent of acute heart failure patients are readmitted within six weeks, continued Selim.
Selim and colleagues hypothesized that among patients admitted for congestive heart failure, those admitted and treated by a specialized cardiology service will have better outcomes than those treated by a general medicine service.
The researchers searched EMRs of patients admitted for heart failure between 1999 to 2009 at Montefiore Medical Center (New York City) and divided patients into two groups: those served by specialized clinicians and those served by internal medicine physicians.
According to the researchers, 2,071 patients were in the specialist group and 6,874 were in the internal medicine group. They examined 60-day readmissions and mortality outcomes and also considered rates for beta-blockers, ACE inhibitors, spironolactone and ICDs and found “clearly significant differences’’ between the groups. “There was inadequate adherence to evidence-based congestive heart failure guidelines by non-specialized physicians,” reported Selim.
Sixty-day mortality and readmissions were higher for the internal medicine patients. Patients on the internal medicine service had a 60-day mortality of 9.7 percent, while the specialist cohort had a rate of 6.2 percent. Readmissions were 25.9 percent for internal medicine patients and 21.5 for the specialized patients.
However, length of stay was higher in the specialist cohort with a mean length of stay of 7.7 days, just shy of a day more than the internal medicine group, which had a mean length of stay of 6.8 days.
“The take home message,” stressed Selim, “is that cardiologists and congestive heart failure services need to be more involved in the management of patients admitted for decompensated heart failure to ensure adequate implementation of guidelines in their institution.”
Variability in AMI readmissions and mortality
“A rising tide does not lift all boats,” observed Vivek Kulkarni, a second-year medical student at Yale University School of Medicine in New Haven. Kulkarni used the analogy in reference to suspected variability among hospitals in terms of acute MI (AMI) readmissions and mortality.
Previous studies have reported improvements in AMI mortality rates from 1995 to 2006. Kulkarni and colleagues sought to determine how individual hospitals have experienced changes in AMI mortality and to characterize patterns of hospital-specific changes in AMI mortality.
They focused on two time periods: January 1995 to December 1998 and January 2006 to December 2008 and employed changes in the risk-standardized mortality rate (RSMR) as the main outcome.
The researchers examined data from 2,643 hospitals and found that the mean RSMR was 18.5 percent in the first time period and 13.9 percent in the latter.
“In general, we observed improvement in RSMR,” noted Kulkarni, who continued, “Although the majority of hospitals have gotten better, 4.4 percent of hospitals are worsening.”
The researchers also found a strong association between worse baseline RSMR and increased improvement in RSMR.
The next step, confided Kulkarni, is to determine which characteristics correlate with improvements and worsening in RSMR, with the ultimate goal of developing an RSMR model.