Critically ill heart, pneumonia patients fare worse at 4 Nashville area hospitals

By Jennifer Brooks • THE TENNESSEAN • July 31, 2009 Your odds of surviving a heart attack may depend on which hospital you visit. That's something Margaret Petre found out first-hand last summer, when she staggered into an emergency room, clutching her chest with one hand and a bottle of nitroglycerine with the other. "I must have looked really bad because they had me flat on my back in the ER within minutes," said Petre, a 47-year-old Nashville native who had two heart attacks in the past five years. "... When you're in that position, you're incapable of making decisions, so you just let it go and say do what you have to do." In an effort to measure how American hospitals are caring for their most critically ill patients, the U.S. Centers for Medicare and Medicaid Services analyzed deaths from heart attack, heart failure and pneumonia at 4,600 hospitals in recent years. While most Middle Tennessee hospitals mirror the average hospital mortality rate, a few showed troubling results. Baptist Hospital scored slightly worse than the national average for deaths from heart failure — something the hospital says reflects faulty paperwork, not poor patient care. Three regional hospitals — Maury Regional Hospital in Columbia, Sumner Regional Medical Center in Gallatin and Gateway Medical Center in Clarksville — scored worse than the national average for deaths from pneumonia. Nationwide, the analysis found hospitals where patients were dying needlessly and hospitals that admitted and readmitted the same cardiac patients over and over. At other hospitals, particularly in wealthier areas, patients enjoyed much higher than average odds of survival and recovery. For every 100 heart attacks at area hospitals, between 14 and 19 percent will die, depending on which hospital they visited. The national average is 16 percent. For heart failure patients, the mortality rate in this region ranged from just under 10 percent to almost 14 percent. The national average is 11 percent. The pneumonia death rate ranged from 9 percent to 16 percent. The national average is 11.5 percent. Needless deaths To keep track of how hospitals care for their most vulnerable patients, the Medicare system tracked hospital admissions and deaths between 2005 and 2008. While Middle Tennessee hospitals fell within the expected death rates, at hundreds of other hospitals around the country, researchers found patients dying needlessly. The Medicare analysis found a wide variation in death rates between the best hospitals and the worst. At 5.9 percent of hospitals, patients with pneumonia died at rates significantly higher than the national average. With heart failure, 3.4 percent of hospitals had death rates higher than the average, and 1.2 percent of hospitals were higher when it came to heart attack. Researchers also found that the majority of U.S. hospitals operate the equivalent of revolving doors for their patients. One of every four heart failure patients and slightly less than one in five heart attack and pneumonia patients land back in the hospital within 30 days. "We have double failure in our health system," said John Rumsfeld of the Denver VA Medical Center and chief science officer for the American College of Cardiology's National Data Registry. None of the failing hospitals was in Middle Tennessee, although a handful of Tennessee hospitals made the list, including Baptist Memorial Hospital in Carroll County, where the heart attack death rate almost tops 22 percent; or the Hardin Medical Center in Savannah, which saw an average of 17 percent deaths in heart failure. Most Nashville-area hospitals had death rates and readmission rates that fell within the statistical average of the national rates. One exception was Baptist Hospital in Nashville, which registered a death rate of 13.8 percent for heart failure. The national average is 11.1 percent. "To be candid, we were surprised by that number," said Elizabeth Lemons, vice president of clinical effectiveness for Saint Thomas Health Services, which includes Baptist Hospital. Baptist sees a large number of patients suffering from congestive heart failure, and prides itself on having full-time heart failure cardiologists on staff, as well as an innovative pilot program aimed at reducing readmission rates. After some investigation, the hospital concluded that the problem was a matter of paperwork. The Medicare analysis used complicated criteria to make a fair comparison between small hospitals and major cardiac centers. Its formula also balanced the deaths of patients with treatable conditions and those so deathly ill they would have died no matter where they were treated. Baptist concluded that it wasn't sharing enough details with the government to identify those deathly ill patients. "At Baptist, we had a culture of 'useful' charting," said cardiologist George Crossley. In other words, staff would take note of medical conditions directly affecting a patient in crisis, but not underlying medical conditions such as diabetes or hypertension. These days the staff takes pains to check all the boxes and fill out all the paperwork. Baptist takes action For the moment, the hospital is more excited about a different set of criteria — readmission rates. Baptist has instituted a pilot program that allows staff to track and monitor patients discharged after treatment for heart failure. Nurses check in with patients, make sure they take their medications and follow their rigorous, low-salt, low-fluid diets and monitor their health. Since the program went into effect, the readmission rate for heart failure dropped to zero after 30 days and 5 percent after six months. The national average is 24 percent. The program is a relatively inexpensive option, certainly compared to the expense of readmitting a patient in heart failure. What worries Crossley, however, is that in all the talk of health-care reform, no one seems to be talking about how to fund preventative programs like this one. The Medicare analysis comes as the White House and Congress debate ways to cut costs and improve quality in the nation's health system. One idea is to reward doctors and hospitals not just for how many procedures they perform but how well their patients fare. More than 200 hospitals have death rates better than the national average, and hundreds fare better on readmission rates. The findings are based on more than 1 million deaths and readmissions among Medicare patients from 2005 to 2008. How well a hospital performs in these evaluations can affect everything from government funding levels for the hospital to patients' decisions about where they will seek help if they fall ill. At Vanderbilt, hospital performance data "drives us, inspires us to do better," said Julie Morath, chief quality and patient safety officer at Vanderbilt University Hospital, which ranked high on the list for patient survival but slightly lower than the national average for readmission rates. "Every time these data come out and we see a hospital that performs better than us, we call them and ask, 'What are you doing?' " she said. "And other hospitals, of course, call us."