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ABSTRACT: Previous studies have identified hospitals with poor performance on cardiac process measures. How these hospitals fare in other domains, such as patient satisfaction, remains unknown.
We used Hospital Compare data to identify hospitals reporting acute myocardial infarction (AMI) and heart failure (HF) process measures during 2006 to 2008, and calculated respective composite performance scores. Using these scores, we classified hospitals as low-performing (bottom decile for all 3 years), top-performing (top decile for all 3 years), and intermediate (all others). We used Hospital Consumer Assessment of Healthcare Providers and Systems 2008 data to compare overall satisfaction between low, intermediate, and top-performing hospitals. Low-performing hospitals had fewer beds, fewer nurses per patient, and were more likely rural, safety-net hospitals located in the South, compared with intermediate and top-performing hospitals (P<0.01 for all). After adjusting for hospital characteristics, patients were less likely to recommend low-performing hospitals to family or friends, relative to intermediate and top-performing hospitals (AMI: 58.8% versus 63.9% versus 68.8%, HF: 61.3% versus 64.0% versus 66.8%; P<0.001 for all), or provide an overall rating of ≥ 9 out of 10 (AMI: 56.7% versus 60.7% versus 64.9%, HF: 57.8% versus 61.1% versus 63.6%; P<0.01 for all). Despite the association between the hospital's performance on process measures and patient satisfaction, we noted discordance between these measures (kappa statistic <0.20).
Hospitals with consistently poor performance on cardiac process measures also have lower patient satisfaction on average, suggesting that these hospitals have overall poor quality of care. However, there is discordance between the 2 measures in profiling hospital quality.
Circulation Cardiovascular Quality and Outcomes 04/2012; 5(3):365-72. · 4.91 Impact Factor
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ABSTRACT: Racial disparities in acute myocardial infarction treatment may be due to differences in admitting hospitals. Little is known about factors associated with hospital selection for black and white acute myocardial infarction patients.
We identified black and white Medicare beneficiaries with acute myocardial infarction in 63 hospital referral regions with at least 50 black admissions during 2005 (n=65,633). We calculated distance from patient home to hospital referral region hospitals using ZIP code centroids. We assessed hospital quality using a composite score made up of hospital risk-adjusted 30-day mortality and acute myocardial infarction performance measures. Hospitals with a score in the top 20% were categorized as high quality, and those in the lowest 20% as low quality. We used conditional multinomial logit models to examine differences in hospital selection for blacks and whites. On average, blacks lived closer to revascularization hospitals (mean, 3.8 versus 6.8 miles; P<0.001) and to high-quality hospitals (mean, 5.6 versus 9.7 miles; P<0.001). After distance was accounted for, blacks were relatively less likely (P<0.001) to be admitted to revascularization hospitals (risk ratio [RR], 0.87; 95% confidence interval [CI], 0.80 to 0.95) and to high-quality hospitals (RR, 0.88; 95% CI, 0.801 to 0.95) but more likely (P<0.001) to be admitted to low-quality hospitals (RR, 1.17; 95% CI, 1.05 to 1.29). In analyses matched by home ZIP code, differences in admissions to revascularization (RR, 0.92; 95% CI, 0.80 to 1.05), high-quality (RR, 0.94; 95% CI, 0.81 to 1.07), and low-quality (RR, 1.15; 95% CI, 0.94 to 1.35) hospitals were not significant.
Differences in admissions to revascularization and high-quality hospitals may contribute to disparities in acute myocardial infarction care. These differences may be due in part to residential ZIP code characteristics.
Circulation 06/2011; 123(23):2710-6. · 14.74 Impact Factor
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ABSTRACT: Hospital volume has been widely embraced as a proxy measure for hospital quality; little attention has been focused on an alternative quality measure-hospital specialization. Even though specialization occurs on a continuum, previous studies have only focused on a small number of highly specialized hospitals (single-specialty hospitals). Studies on the broad relationship between hospital specialization and outcomes after coronary artery bypass grafting (CABG) are limited.
We conducted a retrospective cohort study of 705 084 Medicare patients (1130 hospitals) who underwent CABG during 2001 to 2005. We stratified hospitals into quintiles, based on their degree of cardiac specialization (proportion of a hospital's Medicare discharges classified as Major Diagnostic Category 5-cardiovascular diseases). We compared patient and hospital characteristics and outcomes across quintiles of cardiac specialization. Patient characteristics were generally similar across quintiles, but mean annual CABG volume increased progressively from quintile 1 (least specialized) to quintile 5 (most specialized). Unadjusted 30-day mortality was similar at hospitals in quintiles 1 to 4 (4.8%), except quintile 5, where mortality was lower (4.3%). A strong inverse association was seen between hospital cardiac specialization and 30-day mortality after adjustment for patient characteristics (P(trend)=0.001). However, this was no longer significant after additional adjustment for CABG volume (P(trend)=0.65). Results were similar for other mortality outcomes and length of stay.
After accounting for patient characteristics and CABG volume, greater cardiac specialization was not associated with clinically significant improvement in patient outcomes. This study calls into question the benefit of cardiac specialization for the vast majority of CABG-performing US hospitals.
Circulation Cardiovascular Quality and Outcomes 10/2010; 3(6):607-14. · 4.91 Impact Factor
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ABSTRACT: Research increasingly shows that blacks with coronary heart disease (CHD) are treated at lower-quality hospitals. Little is known about racial differences in admission to high-quality hospitals.
We identified all black and white Medicare patients with acute myocardial infarction and coronary artery bypass grafting (CABG) admitted during 2002 through 2005 to hospitals located in markets with top-ranked cardiac hospitals, as ascertained from the US News and World Report "America's Best Hospitals" annual rankings. The relationship between race and admission to top-ranked hospitals was estimated using multinomial conditional logit models to account for distance from patient residence to all available hospitals.
In unadjusted analyses, blacks with AMI or undergoing CABG, compared with whites, were more likely to be admitted to top-ranked hospitals (18.3% vs 10.5% and 34.4% vs 22.7% [P < .001]) but also more likely to bypass top-ranked hospitals (25.8% vs 14.7% and 37.5% vs 26.3% [P < .001]). In models accounting for distance, blacks with acute myocardial infarction were more likely (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.16 [P < .001]), whereas blacks undergoing CABG were equally likely (OR, 1.05; 95% CI, 0.97-1.13; P = .27) to be admitted to top-ranked hospitals compared with whites. However, within socially disadvantaged zip codes, blacks undergoing CABG were less likely to receive care at top-ranked hospitals (OR, 0.75; 95% CI, 0.64-0.86 [P < .001]) compared with whites and more likely to bypass top-ranked hospitals located closer to their residence (OR, 1.16; 95% CI, 1.02-1.30 [P = .03]).
Black Medicare patients with acute myocardial infarction or undergoing CABG were equally or more likely to be admitted to top-ranked hospitals, except for socially disadvantaged black patients undergoing CABG.
Archives of internal medicine 07/2010; 170(14):1209-15. · 11.46 Impact Factor
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ABSTRACT: There is growing concern certain not-for-profit hospitals are not providing enough uncompensated care to justify their tax exempt status. Our objective was to compare the amount of uncompensated care provided by not-for-profit (NFP), for-profit (FP) and government owned hospitals.
We used 2005 state inpatient data (SID) for 10 states to identify patients hospitalized for three common conditions: acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or childbirth. Uncompensated care was measured as the proportion of each hospital's total admissions for each condition that were classified as being uninsured. Hospitals were categorized as NFP, FP, or government owned based upon data obtained from the American Hospital Association. We used bivariate methods to compare the proportion of uninsured patients admitted to NFP, FP and government hospitals for each diagnosis. We then used generalized linear mixed models to compare the percentage of uninsured in each category of hospital after adjusting for the socioeconomic status of the markets each hospital served.
Our cohort consisted of 188,117 patients (1,054 hospitals) hospitalized for AMI, 82,261 patients (245 hospitals) for CABG, and 1,091,220 patients for childbirth (793 hospitals). The percentage of admissions classified as uninsured was lower in NFP hospitals than in FP or government hospitals for AMI (4.6% NFP; 6.0% FP; 9.5% government; P < .001), CABG (2.6% NFP; 3.3% FP; 7.0% government; P < .001), and childbirth (3.1% NFP; 4.2% FP; 11.8% government; P < .001). In adjusted analyses, the mean percentage of AMI patients classified as uninsured was similar in NFP and FP hospitals (4.4% vs. 4.3%; P = 0.71), and higher for government hospitals (6.0%; P < .001 for NFP vs. government). Likewise, results demonstrated similar proportions of uninsured patients in NFP and FP hospitals and higher levels of uninsured in government hospitals for both CABG and childbirth.
For the three conditions studied NFP and FP hospitals appear to provide a similar amount of uncompensated care while government hospitals provide significantly more. Concerns about the amount of uncompensated care provided by NFP hospitals appear warranted.
BMC Health Services Research 04/2010; 10:90. · 1.66 Impact Factor
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ABSTRACT: Abstract
Background
There is growing concern certain not-for-profit hospitals are not providing enough uncompensated care to justify their tax exempt status. Our objective was to compare the amount of uncompensated care provided by not-for-profit (NFP), for-profit (FP) and government owned hospitals.
Methods
We used 2005 state inpatient data (SID) for 10 states to identify patients hospitalized for three common conditions: acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or childbirth. Uncompensated care was measured as the proportion of each hospital's total admissions for each condition that were classified as being uninsured. Hospitals were categorized as NFP, FP, or government owned based upon data obtained from the American Hospital Association. We used bivariate methods to compare the proportion of uninsured patients admitted to NFP, FP and government hospitals for each diagnosis. We then used generalized linear mixed models to compare the percentage of uninsured in each category of hospital after adjusting for the socioeconomic status of the markets each hospital served.
Results
Our cohort consisted of 188,117 patients (1,054 hospitals) hospitalized for AMI, 82,261 patients (245 hospitals) for CABG, and 1,091,220 patients for childbirth (793 hospitals). The percentage of admissions classified as uninsured was lower in NFP hospitals than in FP or government hospitals for AMI (4.6% NFP; 6.0% FP; 9.5% government; P < .001), CABG (2.6% NFP; 3.3% FP; 7.0% government; P < .001), and childbirth (3.1% NFP; 4.2% FP; 11.8% government; P < .001). In adjusted analyses, the mean percentage of AMI patients classified as uninsured was similar in NFP and FP hospitals (4.4% vs. 4.3%; P = 0.71), and higher for government hospitals (6.0%; P < .001 for NFP vs. government). Likewise, results demonstrated similar proportions of uninsured patients in NFP and FP hospitals and higher levels of uninsured in government hospitals for both CABG and childbirth.
Conclusions
For the three conditions studied NFP and FP hospitals appear to provide a similar amount of uncompensated care while government hospitals provide significantly more. Concerns about the amount of uncompensated care provided by NFP hospitals appear warranted.
BMC Health Services Research. 01/2010;
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ABSTRACT: Racial disparities in coronary revascularization--percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)--have been extensively documented. However, it is unclear whether disparities are consistent among patients with similar health insurance coverage. Our objective was to assess racial disparities in coronary revascularization among white, black, and Hispanic patients with similar insurance coverage hospitalized with acute myocardial infarction (AMI).
We used 2000-2005 state inpatient data for 9 states to identify white, black, and Hispanic patients hospitalized with AMI. Patients were grouped into 3 health insurance cohorts: (1) Medicare, (2) private insurance, and (3) Medicaid/uninsured. We examined use of revascularization (PCI or CABG) among blacks and Hispanics as compared to whites in each of the 3 insurance cohorts.
The 418 study hospitals admitted 430509 AMI patients with Medicare, 238956 with private insurance, and 74926 patients who were uninsured/Medicaid. In unadjusted analyses, black and Hispanic patients were significantly less likely to receive in-hospital revascularization among the Medicare cohort (38.9% vs 44.9% vs 47.3%, P < .001), privately insured cohort (62.9% vs 69.7% vs 74.2%, P < .001), and uninsured/Medicaid cohort (55.2% vs 61.0% vs 68.4%, P <.001). In Cox models adjusting for patient demographics, comorbidity, and clustering of patients within hospitals, blacks were approximately 25% less likely and Hispanics 5% less likely to receive revascularization as compared to whites with similar insurance.
Blacks hospitalized with AMI are significantly less likely to receive revascularization when compared to whites and Hispanics with similar health insurance. Our data suggest that patients' ability to pay for costly procedures is unlikely to explain racial disparities.
Journal of the National Medical Association 11/2009; 101(11):1132-9. · 1.16 Impact Factor
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Stephan D Fihn,
Mary Vaughan-Sarrazin,
Elliott Lowy, Ioana Popescu,
Charles Maynard,
Gary E Rosenthal,
Anne E Sales,
John Rumsfeld,
Sandy Piñeros,
Mary B McDonell,
Christian D Helfrich,
Roxane Rusch,
Robert Jesse,
Peter Almenoff,
Barbara Fleming,
Michael Kussman
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ABSTRACT: Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining.
We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files.
Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08).
Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.
BMC Cardiovascular Disorders 09/2009; 9:44. · 1.52 Impact Factor
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ABSTRACT: Studies suggest that most hospitals now have relatively high adherence with recommended acute myocardial infarction (AMI) process measures. Little is known about hospitals with consistently poor adherence with AMI process measures and whether these hospitals also have increased patient mortality.
We conducted a retrospective study of 2761 US hospitals reporting AMI process measures to the Center for Medicare and Medicaid Services Hospital Compare database during 2004 to 2006 that could be linked to 2005 Medicare Part A data. The main outcome measures were hospitals' combined compliance with 5 AMI measures (aspirin and beta-blocker on admission and discharge and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use at discharge for patients with left ventricular dysfunction) and risk-adjusted 30-day mortality for 2005. We stratified hospitals into those with low AMI adherence (ranked in the lowest decile for AMI adherence for 3 consecutive years [2004-2006, n=105]), high adherence (ranked in the top decile for 3 consecutive years [n=63]), and intermediate adherence (all others [n=2593]). Mean AMI performance varied significantly across low-, intermediate-, and high-performing hospitals (mean score, 68% versus 92% versus 99%, P<0.001). Low-performing hospitals were more likely than intermediate- and high-performing hospitals to be safety-net providers (19.2% versus 11.0% versus 6.4%; P=0.005). Low-performing hospitals had higher unadjusted 30-day mortality rates (23.6% versus 17.8% versus 14.9%; P<0.001). These differences persisted after adjustment for patient characteristics (16.3% versus 16.0% versus 15.7%; P=0.02).
Consistently low-performing hospitals differ substantially from other US hospitals. Targeting quality improvement efforts toward these hospitals may offer an attractive opportunity for improving AMI outcomes.
Circulation Cardiovascular Quality and Outcomes 05/2009; 2(3):221-7. · 4.91 Impact Factor
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ABSTRACT: Supporters of specialty hospitals claim these facilities provide better patient care; however, empirical data on quality of care in specialty hospitals are limited.
We used data reported to the Centers for Medicare and Medicaid Services (CMS) during 2005 to 2006 to compare the quality of care of specialty cardiac hospitals, competing general hospitals and a group of top-ranked cardiac hospitals as identified by the US News & World Report's list of "America's best cardiac hospitals" for acute myocardial infarction (AMI) and heart failure (HF). The main outcome was hospital compliance with CMS performance measures, expressed as the percentage of eligible patients with AMI or HF who received guidelines-based treatment.
The mean compliance for all 179 hospitals was 95% for AMI measures, 91% for HF measures, and 94% for all cardiac care (AMI plus HF measures). Specialty hospitals' compliance with AMI and HF guidelines (95.2% and 91.3%) was similar to that of competing general hospitals (94.7% and 90.5%), whereas top-ranked cardiac hospitals compliance with both AMI and CHF measures (96.8% and 94.1%) was higher (P < .001). In supplemental analyses, we found that 40% of specialty hospitals were ranked in the top quartile of all 179 hospitals, as compared with 22.9% of top-ranked cardiac hospitals. Conversely, 25% specialty hospitals were in the lowest quartile, as compared to 7% of top-ranked cardiac hospitals.
Quality of care in specialty cardiac hospitals is similar to quality in competing general hospitals and top-ranked cardiac care hospitals, as measured by compliance with AMI and HF performance indicators. Quality of care appears to be slightly better for top-ranked cardiac hospitals as compared to general hospitals, but the overall performance of all hospitals is high.
American heart journal 07/2008; 156(1):155-60. · 4.65 Impact Factor
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ABSTRACT: Racial differences in the use of coronary revascularization after acute myocardial infarction (AMI) have been widely reported. However, few studies have examined patterns of care for AMI patients admitted to hospitals with and without revascularization services.
To compare rates of hospital transfer, coronary revascularization, and mortality after AMI for black and white patients admitted to hospitals with and without revascularization services.
Retrospective cohort study of 1,215,924 black and white Medicare beneficiaries aged 68 years and older, admitted with AMI between January 1, 2000, and June 30, 2005, to 4627 US hospitals with and without revascularization services.
For patients admitted to nonrevascularization hospitals, transfer to another hospital with revascularization services; for all patients, risk-adjusted rates of 30-day coronary revascularization and 1-year mortality.
Black patients admitted to hospitals without revascularization were less likely (25.2% vs 31.0%; P<.001) to be transferred. Black patients admitted to hospitals with or without revascularization services were less likely to undergo revascularization than white patients (34.3% vs 50.2% and 18.3% vs 25.9%; P<.001) and had higher 1-year mortality (35.3% vs 30.2% and 39.7% vs 37.6%; P<.001). After adjustment for sociodemographics, comorbidity, and illness severity, blacks remained less likely to be transferred (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.75-0.81; P<.001) and undergo revascularization (HR, 0.71; 95% CI, 0.69-0.74; P<.001; and HR, 0.68; 95% CI, 0.65-0.70; P<.001 in hospitals with and without revascularization, respectively). Risk-adjusted mortality was lower for blacks during the first 30 days after admission (HR, 0.91; 95% CI, 0.88-0.93; P<.001; and HR, 0.90; 95% CI, 0.87-0.92; P<.001 in hospitals with and without revascularization, respectively) but was higher (P<.001) thereafter.
Black patients admitted to hospitals with and without coronary revascularization services are less likely to receive coronary revascularization. The higher long-term mortality of black patients may reflect the lower use of revascularization or other aspects of AMI care.
JAMA The Journal of the American Medical Association 06/2007; 297(22):2489-95. · 30.03 Impact Factor
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ABSTRACT: Certificate of need regulations were enacted to control health care costs by limiting unnecessary expansion of services. While many states have repealed certificate of need regulations in recent years, few analyses have examined relationships between certificate of need regulations and outcomes of care.
To compare rates of coronary revascularization and mortality after acute myocardial infarction in states with and without certificate of need regulations.
Retrospective cohort study of 1,139,792 Medicare beneficiaries aged 68 years or older with AMI who were admitted to 4587 US hospitals during 2000-2003.
Thirty-day risk-adjusted rates of coronary revascularization with either coronary artery bypass graft surgery or percutaneous coronary intervention and 30-day all-cause mortality.
The 624,421 patients in states with certificate of need regulations were less likely to be admitted to hospitals with coronary revascularization services (321,573 [51.5%] vs 323,695 [62.8%]; P<.001) or to undergo revascularization at the admitting hospital (163,120 [26.1%] vs 163,877 [31.8%]; P<.001) than patients in states without certificates of need but were more likely to undergo revascularization at a transfer hospital (73,379 [11.7%] vs 45,907 [8.9%]; P<.001). Adjusting for demographic and clinical risk factors, patients in states with highly and moderately stringent certificate of need regulations, respectively, were less likely to undergo revascularization within the first 2 days (adjusted hazard ratios, 0.68; 95% confidence interval [CI], 0.54-0.87; P = .002 and 0.80; 95% CI, 0.71-0.90; P<.001) relative to patients in states without certificates of need, although no differences in the likelihood of revascularization were observed during days 3 through 30. Unadjusted 30-day mortality was similar in states with and without certificates of need (109,304 [17.5%] vs 90,104 [17.5%]; P = .76), as was adjusted mortality (odds ratio, 1.00; 95% CI, 0.97-1.03; P = .90).
Patients with acute myocardial infarction were less likely to be admitted to hospitals offering coronary revascularization and to undergo early revascularization in states with certificate of need regulations. However, differences in the availability and use of revascularization therapies were not associated with mortality.
JAMA The Journal of the American Medical Association 06/2006; 295(18):2141-7. · 30.03 Impact Factor
