Choice of hospital in Minnesota can put odds against you

  • Article by: MAURA LERNER , Star Tribune
  • Updated: May 14, 2010 - 11:10 AM

Your chance of dying may depend on which hospital treats you, data suggest. The numbers are prompting head-scratching, soul-searching -- and changes.

Patti Strong, 80, goes through a daily ritual to watch for danger signs that could send her back to the hospital. She has congestive heart failure, a chronic and sometimes disabling disease.

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The two small-town hospitals could hardly be more alike. Just 20 miles apart in southern Minnesota, they're both run by the Mayo Health System and even share some of the same doctors.

Yet in Albert Lea, patients hospitalized with heart failure are twice as likely to die as those in neighboring Austin, government data show.

That kind of gap may seem improbable, especially in a state known for first-rate medical care. But new ratings published by the federal government have found startling disparities in hospital performance all across Minnesota.

In Minneapolis, for example, the risk of dying from a heart attack can vary by as much as 40 percent, depending on where you're hospitalized. The chance of being readmitted within 30 days -- often a sign of medical complications -- is 50 percent higher at some Twin Cities hospitals than at others.

"This country has a very serious quality and safety gap," said Janet Corrigan, of the National Quality Forum in Washington, D.C. Yet patients, and even doctors, are often in the dark, she said.

Hospital officials say the federal statistics can be misleading and make even good medical centers look bad.

But the ratings, compiled annually and published on a federal website, are forcing the medical profession to confront a problem many have ignored until now: There are unnecessary variations in the way hospitals deliver care, and thousands of patients are dying or suffering needlessly as a result, with billions of dollars wasted in the process.

'Any institution needs to look at that number in a cold hard light and say: What's this telling me?" said Dr. Greg Gilmet, chief medical officer of Blue Cross and Blue Shield of Minnesota. "You begin to ask the question, why is there variation? That's the beginning of an interesting journey."

Vast gaps

Until a few years ago, it was almost impossible for consumers to find out how hospitals compared on such life-and-death indicators.

"We can get information on the safety of a car, we can get information on the performance of a stock, yet for years we never had a clue how our doctors and hospitals are providing care, whether it's quality care," said Jennifer Sweeney, director of Americans for Quality Health Care, a national consumer advocacy program.

Now that's changing.

Since 2007, the federal agency that runs Medicare has compiled data to grade hospitals. Using its vast database (Medicare covers more than 44 million people) and controlling for the fact that some hospitals see more severe cases than others, it has tracked patients with three common conditions: heart attacks, congestive heart failure and pneumonia. To see how they fared, it calculates how many die or end up back in the hospital within 30 days.

Nationally, the gaps can be vast. Depending on which hospital you walk (or are carried) into, your chances of dying from a heart attack range from 1 in 10 to nearly 1 in 4.

In Minnesota, the gaps are less dramatic, but just as surprising. In St. Cloud, 12.5 percent of patients die following a heart attack; at Hennepin County Medical Center, it's close to 20 percent. In Austin, heart-failure patients have an 8.3 percent death rate; in Albert Lea, it's nearly 16 percent.

The data are posted on a website called HospitalCompare.hhs.gov. (An interactive chart, showing how Minnesota hospitals stack up, can be found at www.startribune.com/hospitalscores.) Although Medicare mainly serves the elderly, it's the nation's largest payer of hospital bills, covering more than 1 in 7 Americans. That sweep gives it a unique ability to compare hospitals.

Motivating change

The ratings don't quite explain why some hospitals perform better than others, and there's little evidence that consumers use them to shop around for care.

But hospitals are paying attention.

"If I'm running a hospital, I want it to be as good as my neighbors," said Dr. Gordon Mosser, an expert in quality measurement at the University of Minnesota School of Public Health. "Once the numbers start getting reported, they start caring a lot."

Dr. Penny Wheeler, chief clinical officer at Allina Hospitals & Clinics, was taken aback when she first saw the numbers. Last year, 14 Minnesota hospitals stood out as significantly better -- or worse -- than their peers nationwide (see chart). Allina had hospitals at both extremes, including three in the bottom group on certain indicators: Mercy Hospital in Coon Rapids, St. Francis Regional Medical Center in Shakopee and Unity Hospital in Fridley.

Her initial reaction: "This doesn't look like exceptional care to us," she said. "We'd better find out what's going on."

At Mercy, officials were stumped. Just months before, Mercy had been named one of the nation's top 100 heart hospitals for the sixth year in a row by Thomson Reuters, the law and publishing giant.

Yet the Medicare data, released in July 2009, told a different story.

Mercy had an unusual spike in readmissions for heart-attack patients from 2005 to 2008: 24 percent were back in the hospital within 30 days. In Medicare's analysis, that was the highest rate in Minnesota, and a possible sign of substandard care. "I think my first reaction was: Show me the data," said Dr. Dennis O'Hare, the hospital's vice president of medical affairs.

Staffers combed through patient records for an explanation. O'Hare said he never found one but concluded that the numbers were out of date. "My top question was: Is this still a problem? The answer to that was, it's not. ... Whatever was happening back then was no longer going on."

Other hospitals, too, insist the scores can be misleading.

"The most likely scenario is that this is more a question of coding than care," said Dr. Brian Prokosch, vice president of medical affairs at St. Francis. His hospital had the highest rate of pneumonia readmissions in Minnesota, 22.6 percent. "There was a blip in 2007, but ... it's gone," he said. "We're actually better than [the] national average."

Mayo, like Allina, had hospitals at both ends of the spectrum. "Does it really say that this hospital is inferior to that hospital? The answer is no," said Dr. Robert Lohr, an internist at the Mayo Clinic. "The statistical difference between Albert Lea and Austin can be completely chance."

Not a fluke

National experts, however, say that's not likely.

Some differences are simply too large to brush off as flukes, said Lein Han, a Medicare senior adviser and data expert.

Most hospitals fall into a broad statistical middle ground, with scores that are comparable given their patients' health. Fewer than 10 percent score so far outside the statistical norm that Medicare labels them "better than" or "worse than" the rest.

She added that Medicare has access to information that individual hospitals do not. Because it pays the bills for millions of people, it can track when a patient leaves one hospital and winds up at another.

So if hospitals score at opposite extremes, she said, "there are very likely true quality" differences there.

Soul-searching

Even among hospital executives, there's growing acceptance that public comparisons, though painful, can be a healthy thing.

"It certainly creates the soul-searching when you see those numbers," said Wheeler, of Allina. It also pierces the myth that everyone is above average. As one doctor told her: "We were legends in our own minds."

For some, the simple realization that they've fallen behind has sparked a transformation. At the Austin Medical Center, Dr. Cynthia Dube noticed the red flags several years ago. At the time, the hospital's own data showed that heart-failure patients weren't doing as well as expected. Among other things, records showed, only about 80 percent were getting proper discharge instructions, said Dube, the medical director.

She started asking why. It turned out that patients were supposed to get the instructions right before leaving, but if the nurses got distracted, they sometimes forgot. Without instructions, patients are more likely to miss danger signs or skip medications, which can land them right back in the hospital.

To prevent that, the hospital started putting discharge instructions in the admission packets, which every patient gets on arrival. It also made other changes: assigning a nurse to make sure heart-failure patients got the right medications and tests while still in the hospital.

By 2009, Austin ranked among the best in the nation in two Medicare categories, including heart-failure deaths.

Whether Austin's improvement resulted from Dube's changes -- or were simply a coincidence -- isn't clear.

There is plenty of evidence, though, that hospitals don't always follow recommended care guidelines, even when there is broad professional consensus on what's best for the patient.

It's widely known, for example, that aspirin can be a lifesaver for patients having a heart attack. But 5 percent of Minnesota heart-attack patients didn't get aspirin when they got to the hospital, according to the 2009 Medicare data.

Doctors also know that giving patients antibiotics before surgery can prevent infection. But in Minnesota hospitals, 13 percent didn't get the recommended antibiotics, the data show. Among heart-failure patients, fully 30 percent went home without discharge instructions.

Some hospitals manage to do all three nearly 100 percent of the time.

Others don't come close.

Daily ritual

Sometimes the pivotal difference doesn't take place inside the hospital, but after the patient heads home.

Just ask 80-year-old Patti Strong of Wayzata.

In 2001, she was taken by ambulance to Methodist Hospital, struggling to breathe. Like many people with congestive heart failure, she landed back in the hospital numerous times. At Methodist, they're known as "frequent fliers."

Several years ago, the hospital started trying to head off those return trips by helping patients monitor their symptoms at home. Strong was only too happy to take part.

Now, she starts every day with a ritual: stepping on the scale, calling an automated phone line and reporting her weight and symptoms. With heart failure, sudden weight gain is a danger sign; it can mean the heart isn't pumping properly. If she reports any trouble, a nurse calls back, ready to adjust her medication or arrange a quick trip to the doctor.

Those daily check-ins, Strong said, have kept her out of the hospital for more than three years.

For nearly 20 years, Methodist has been obsessively tracking patient outcomes, said Dr. David Abelson, chief executive of Park Nicollet Health Services, which owns the hospital. "There are times when we need to look at ourselves in the mirror," Abelson said, and ask: "What can we learn here?"

In 2009, Methodist had one of the lowest readmission rates for heart failure patients in Minnesota: 20 percent, according to Medicare.

The implicit message to everyone else: If Methodist can do it, why do some Twin Cities hospitals have readmission rates of 27 percent (the University of Minnesota Medical Center), 28 percent (Hennepin County Medical Center) and 29 percent (Unity)?

"That's pretty good evidence that a deliberate effort can improve the numbers," said Mosser, of the university.

Patient, or hospital?

Skeptics say it's unrealistic to expect the same results everywhere.

"These 30-day [re]admissions have very little to do with the hospital care; they have everything to do with the patients," said Dr. Bradley Bart, chief of cardiology at HCMC.

"If they're unemployed and they can't afford their medications, or they don't have a phone, how's the hospital going to fix that?" Bart asked. He also points out that HCMC's scores are within the national average, and no different than those of other big teaching hospitals.

Still, there's growing recognition that patients will keep coming back, or die prematurely, without more help.

"I don't think our responsibility ends at the hospital door," said Wheeler, of Allina. "Now we're looking much more carefully at how we can help them."

No one expects hospitals to solve the problems themselves, said Corrigan, of the National Quality Forum, an advocacy group. But they have to start somewhere. "We know that 75 percent of readmissions are avoidable," Corrigan said. "That's called waste."

That's also one reason Medicare has focused attention on hospital performance: Solving the problem could save billions of dollars.

Starting in 2011, Medicare will have authority to cut reimbursements to hospitals with excessive readmissions. Private insurers may follow suit.

With that in mind, many hospitals have begun campaigns to reduce readmission and death rates, including HCMC, Allina, Fairview and Mayo.

One of them is the Albert Lea Medical Center. The reforms were already in the works before last summer's ratings, said Dr. John Grzybowski, the medical director. But the Medicare scorecards could well speed things up. "It's going to help mainly because we're all competitive people," he said. No one, after all, wants to be last. "Most of us want to be the best."

Maura Lerner • 612-673-7384 Staff writer Glenn Howatt contributed to this report.

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