Friday, June 15, 2007

Pennsylvania Study Protects Consumers

Heart surgeries don’t fare well on state survey

High death rate found in one class of operations at Altoona during 2005

A state group that tracks health care performance found a high death rate for Altoona Regional Health System and one of its surgeons for one type of heart operation in 2005.

The Pennsylvania Health Care Cost Containment Council found the higher-than-expected death rate for heart valve operations in patients who died at the hospital or within 30 days of their procedures.

The high death rate finding for the hospital was based on 59 valve operations.

The same finding for Dr. John Anastasi was based on the 50 valve operations he performed.

The hospital spoke of extenuating circumstances in a letter about the findings to the agency.

“The patients that did not fare well in the current reporting period had many complicating factors, including very advanced age, end-stage heart disease, whose only remaining option was surgery, and emergency cases performed during an acute life-threatening event,” wrote David Cowger, senior vice president of quality/medical affairs. “Many of these patients had pre-existing multi-organ disease compounding their acute cardiac care. Patient and family directives frequently limited the amount of support we could provide.”

To calculate red-flag rates, the agency uses a formula that takes into account how sick patients are.

The council also found higher-than-expected readmission rates within seven days and 30 days for the valve operations at the hospital and for those done by Anastasi.

And it found a higher-than- expected readmission rate within 30 days for the 89 coronary artery bypass graft surgeries performed by Anastasi.

The council, a quasi-governmental agency, tracks and reports performance by hospitals and in some cases individual doctors because “there is evidence that information contained in reports such as this encourages hospitals and surgeons to examine their processes and make changes that can improve quality of care and ultimately save lives,” the agency stated in its report.

Altoona constantly monitors its care to improve outcomes, Cowger wrote. All cases of “less-than-optimal outcome are reviewed,” he wrote.

The open-heart surgery team at the hospital has not had significant changes since it began in 1989, he wrote.

The 2005 report also lists Dr. Burt Fazi as performing heart surgery.

Statewide, the council found the in-hospital death rate for coronary bypass surgery patients declined in 2005, while the rates of readmission increased slightly during the same period.

The 2005 mortality rate among bypass patients was 1.9 percent, down from nearly 2 percent the previous year and from 2.4 percent in 2000.

At the same time, 5.5 percent of bypass patients were readmitted within seven days of being discharged — up from 5.2 percent — and 13.6 percent were readmitted within 30 days of being discharged, up from 13.2 percent.

Heart failure, infections and abnormal heart rhythms were the top three reasons for readmissions.

The council has published annual reports on bypass surgeries and how much hospitals charge for them since 1992. This year, it added information on heart-valve procedures, which are more invasive and complicated than bypasses, and included payment data on both procedures for the first time.

‘‘The provider community has argued for a long time that [hospital] charges do not reflect what is paid,’’ said Marc P. Volavka, the council’s executive director. ‘‘The public now has available precisely the kind of information they’re going to need.’’

UPMC was paid thousands more for cardiac surgery

But study says care, measured by deaths and readmissions, was not superior to lower-cost hospitals

A ground-breaking report released today reveals wide disparities in the amounts Pittsburgh-area hospitals received for cardiac surgeries, with the University of Pittsburgh Medical Center paid thousands more than its rivals without offering a superior level of care as measured by mortality and readmission rates.

The variations are no surprise to insurers, who provided 2005 payment data for the report, produced by the Pennsylvania Health Care Cost Containment Council. And consumers are unlikely to change hospitals based on the pricing information because health plans shoulder the bulk of the cost of their care.

But one small business representative hopes the new data will motivate employers to demand a greater equality in pricing from hospital to hospital.

"If you are going to charge more, you have to show a better result," said Cliff Shannon, who represents small- and medium-sized manufacturers as president of SMC Business Councils in Churchill. "That is what we expect when we buy a car. God knows, health care is more important than the car we drive."

Referring to UPMC, the nonprofit hospital conglomerate that has major operations in Oakland, he asked: "What kind of rational decision is it to go into the city, find parking in Oakland and have the surgery cost 50 percent more? For a lot of employers, those are the questions that will echo in their heads as they think about their next health care budget."

The two highest-paid hospitals, according to the state agency that seeks to address the cost and quality of health care, were UPMC Presbyterian and UPMC Shadyside, two of 19 institutions controlled by the region's dominant medical provider and biggest employer. Together, in 2005, the East End hospitals received an average of $34,803 for coronary artery bypass graft surgery -- used on patients with significant artery blockage.

No hospital in the area received more. The average payment for the same procedure at the North Side's Allegheny General Hospital was $23,715, while at Jefferson Regional Medical Center in the South Hills, the cost was even lower: $18,009.

Yet the level of care at Jefferson Regional and Allegheny General, as measured by mortality and re-admission rates, was not inferior to that at the two UPMC facilities. In fact, Allegheny General had a lower readmission rate than its crosstown rival.

"There are dramatic differences in payment within the region that don't make a lot of sense," said Marc Volavka, executive director of the cost containment council. "Someone has to ask, 'Why'?"

The statewide report "shows that quality of care has no apparent relationship to the cost of care," said Mr. Shannon, also a board member of the cost containment council. "More expensive does not equal better; less expensive does not equal worse. How much of a premium should we have to pay to go to the brand-name hospitals in Pittsburgh when the quality of care is no better?"

The release of this report, more than a year in the making, provides greater transparency to the often-opaque discussion of rising health care costs across the region and the state

The report is unusual for including average payments made to hospitals for patients covered by commercial insurance. Past reports typically included "charges" -- the amount a hospital bills for a patient's care -- but not the final payment. Hospitals generally do not receive full reimbursement for their charges because insurers or other large purchasers negotiate discounts.

While the two UPMC hospitals had the highest commercial payment rate in the region for coronary artery bypass surgery, some hospitals elsewhere in the state were paid more.

Philadelphia's Hahnemann University, for example, had an average payment of $78,312. At the Hospital of the University of Pennsylvania, the figure was $60,733. Temple, also in Philadelphia, was paid $57,533 for the same procedure.

UPMC spokesman Wendy Zellner cited those differences as a better point of comparison, since they are all academic medical centers, like UPMC, and in that group, UPMC Presbyterian and Shadyside have the highest volume of bypass surgeries and the lowest average payment rates.

Within southwestern Pennsylvania, "various factors affect average charges and payment, including the nature and complexity of the cases that we treat," Ms. Zellner said. The growth in patient volume at UPMC "suggests that insurers and patients believe that we are providing high quality care at a fair price."

Higher prices for UPMC services were an issue last month when the state attorney general's office announced an agreement regarding the planned merger of the region's largest health system with Mercy Hospital.

State officials didn't want the merger to result in higher prices at Mercy, noting that they are currently lower than at UPMC. Health system officials agreed to extend existing health plan contracts at Mercy and their pricing for eight years, with allowances for inflation. Before it could take place, the merger also would need approval from the Federal Trade Commission and the Vatican.

At Mercy, the average payment for a coronary artery bypass was $25,315 -- almost $10,000 less than at the two UPMC facilities (but more than the $24,834 paid to UPMC Passavant, a community hospital in the North Hills). "I don't know if I can explain that great discrepancy," said Dr. Ross DiMarco Jr., chief of cardiovascular and thoracic surgery at Mercy.

West Penn Allegheny Health System, parent of the West Penn Hospital and Allegheny General, raised the same question yesterday, noting that its hospitals performed "on par or better" than the two UPMC hospitals in the East End and still UPMC is paid more.

"In any other market, quality and efficiency are rewarded," said Tom Chakurda, spokesman for West Penn Allegheny. "That does not appear to be the case in health care."

Despite the variation in payment, mortality and hospital readmission rates at local hospitals were generally what would be expected for bypass and valve surgeries, according to the cost containment council report. Some facilities, including Allegheny General, St. Clair Memorial and The Medical Center, Beaver, had lower-than-expected rates for some surgeries. Washington and Westmoreland Regional hospitals, however, had some that were higher than expected.

For a variety of reasons, large medical centers are able to negotiate higher payment rates from insurers or other purchasers, said Dr. Carey Vinson, vice president for quality and medical performance management at Highmark.

The medical care they provide, along with teaching and research, represent "a unique set of services to the community," Dr. Vinson said. "They parlay that into asking for greater reimbursement."

Large centers also contend they treat more complex needs and have higher costs, he said.

But smaller hospitals also try to strengthen their negotiating position -- for example, by noting if they are the only medical facility in a particular area, Dr. Vinson said.

"All hospitals try to leverage their uniqueness when they can," he said.

Medicare payment rates for the cardiac surgeries also varied, according to the report. Medicare officials noted that those rates can be affected by a number of factors, including whether hospitals are teaching facilities or serve large numbers of poor patients.

The report also noted that mortality rates, lengths of stay and payments were much higher when patients having the cardiac surgeries acquired infections in the hospital.

Jessica Seabury, executive director of the Consumer Health Coalition, said payment incentives are needed that better promote good care. Her group works to increase access to quality, affordable health care in southwestern Pennsylvania.

Carolyn Scanlan, president of the Hospital & Healthsystem Association of Pennsylvania, the hospital industry's main lobby in the state, noted that the report indicates that in-hospital mortality rates for cardiac bypass surgeries have continued to drop. She said more study is needed concerning the payment data and information on hospital-acquired infections and lengths of stay.

Wednesday, June 13, 2007

Maltreatment of Black Medicare Patients

A new U.S. study finds that black Medicare patients who have a heart attack are less likely than whites to get procedures that open their blood vessels, such as angioplasty, which can leave them more vulnerable to dying within a year.

The study used recent data to confirm and update knowledge of racial disparities persisting in the health care system.

"We found some significant differences, and definitely, we have no good explanation for why," said lead researcher Dr. Ioana Popescu, health services researcher at Iowa City VA Medical Center. "More research needs to be done."

The study is published in the June 13 issue of the Journal of the American Medical Association.

"This study uses a contemporary cohort, following patients through 2005, and this is the first study to look at that," said Popescu, who is also a junior faculty member at the University of Iowa Carver College of Medicine in Iowa City.

The study also differs from previous research in that it stratifies patients by hospital type, meaning those that do and do not provide specialized heart services.

Prior studies have indicated that racial differences in care after a heart attack appear most pronounced when it comes to invasive and costly technologies such as coronary revascularization or procedures to get the blood flowing again to the heart.

The most common type of revascularization is coronary artery bypass graft (CABG).

Some recent studies have suggested that differing access to high-quality providers might account for some racial disparities.

Less than one-fifth of U.S. acute-care hospitals provide coronary revascularization, and many Medicare beneficiaries are initially admitted to hospitals that don't provide CABG or percutaneous coronary intervention (PCI, formerly known as angioplasty).

Few studies have looked at such patterns of care and how they might impact disparities.

For this study, the authors looked at more than 1.2 million black and white Medicare beneficiaries aged 68 and older who had been admitted to one of 4,627 U.S. hospitals between 2000 and 2005 with a heart attack. The hospitals were mixed, some having revascularization services and some not.

Black patients admitted to hospitals with or without revascularization services were less likely to undergo revascularization than white patients (34.3 percent vs. 50.2 percent and 18.3 percent vs. 25.9 percent) and were also more likely to die within one year (35.3 percent vs. 30.2 percent and 39.7 percent vs. 37.6 percent).

In addition, black patients admitted to hospitals without these specialized services were less likely to be transferred to a hospital with the services within two days (7.4 percent versus 11.5 percent) and within 30 days (25.2 percent versus 31 percent) of admission.

The likelihood that a black patient admitted to a hospital without revascularization services would be transferred was also 22 percent lower than their white counterparts, the team found.

Even among patients who were transferred, blacks were 23 percent less likely to undergo revascularization.

Blacks had a 9 percent lower risk of death during the first 30 days after admission to the hospitals with revascularization services and 10 percent lower in the other hospitals. Between 30 days and one year after admission, blacks had a 12 percent to 26 percent higher risk of death. The risks were lower if the patient underwent revascularization but were still higher than for whites.

Some aspects of the data were unclear, however, including what type of heart attack the participants suffered. The guidelines for revascularization can be different depending on the characteristics of the heart attack, noted Dr. John P. Erwin III, associate professor of internal medicine at Texas A&M Health Science Center College of Medicine and cardiologist at Scott & White Hospital in Temple.

It's also unclear why such disparities exist.

"Probably we should look at other potential contributors to the differences that we notice such as more clinical information on patients," Popescu said. "There may be some underlying baseline differences such as symptoms in the beginning, the time they chose to come to the hospital, which may play role in getting the procedure and the diagnosis. Definitely we need more research into patient preferences and decision-making."

"Aspects of medical decision-making were unclear," Erwin added. "More data points would have helped us understand it."

For Dr. John Underwood, a cardiologist in Scottsdale, Ariz., and past president of the Association of Black Cardiologists, the findings confirm previous patterns seen in medicine. And if patients aren't undergoing procedures such as revascularization, then they're less likely to be followed up.

"You're not tied into the system, those things aren't happening, and people are dying," he said.

CABG may adveresly affect brain function

Patients whose blood pressure drops during heart surgery may have short-term cognitive declines or suffer small strokes, say U.S. researchers.

Researchers at Johns Hopkins School of Medicine in Baltimore assessed 15 patients, age 57 to 81, who underwent coronary artery bypass graft surgery and were believed to be at high risk for postoperative stroke.

All 15 patients took the Mini-Mental Status Examination before surgery, which measures thinking, learning, and memory. Their mean arterial blood pressure, or MAP, which estimates the pressure of the blood that perfuses the organs of the body, was taken before and during surgery. Thirteen patients also underwent postoperative magnetic resonance imaging of their brains.

The researchers found that patients whose MAP decreased by 27 millimeters or mercury or more during surgery scored significantly lower on the Mini-Mental Status Examination after surgery.

The team also found that six of the 13 people who underwent MRIs had evidence of acute strokes, and those who had the 27-plus millimeter drop in MAP were 2.7 times as likely to have such a lesion as those whose MAP decreased by a smaller amount.

The researchers said the cognitive declines they noted might be partially due to the strokes, and proposed further studies to define the relationship between operative MAP drop, stroke and poorer short-term postoperative cognitive performance.

A report on the research appears in the early online edition of the August issue of Archives of Neurology.

Tuesday, June 05, 2007

Don't be deceived

The following story appeared on

Cardiac Surgery Death Rates Decline To Lowest Level In A Decade


Cardiac Surgery Death Rates

Cardiac surgery death rates have dropped to their lowest level since the New Jersey Department of Health and Senior Services began issuing reports a decade ago.

The state's mortality rate has declined 54.5 percent between 1994 and 2004, including a nearly 12 percent drop from 2003 to 2004, according to the report.

"The cardiac surgery reporting initiative is a real success story. It shows what a powerful difference we can make when we work together with one goal in mind -- giving every patient high-quality care," Commissioner Jacobs said.

"Cardiac surgery programs have succeeded because of their remarkable efforts to examine the care they give and make systematic improvements," said Charles Dennis, M.D., chairman of the Commissioner's Cardiovascular Health Advisory Panel. "I appreciate the Department's ongoing support for the panel's efforts to track and report on patient outcomes."

The Cardiac Surgery in New Jersey series focuses on a common cardiac surgical procedure – coronary artery bypass graft (CABG) surgery with no other major surgery during the same hospital admission.

Included in the report are patient mortality data for New Jersey's 17 cardiac surgery hospitals and 49 individual named surgeons. For the first time, the report also includes each hospital's average length of patient stay following surgery.

According to the report released today, the number of CABG surgeries continues to decline as patients are increasingly treated with angioplasty, a less invasive alternative to bypass surgery. There were 6,177 procedures in 2004 compared with a high of 8,377 in 1998. ( How many were treated medically in those years?)

Of the 6,177 patients, 122 -- or 1.98 percent -- died in the hospital or within 30 days of surgery. (How many patients treated with medication died in the first 30 days of treatment?) In 1994-1995, the period covered by the first report, the rate was 4.14 percent. The department risk-adjusts all hospital and surgeon rates to, in effect, give "extra credit" to those treating sicker patients.

Other hospital findings include:

* Hackensack University Medical Center was the only hospital with a statistically significantly better-than-average performance (0.65 percent death rate).

* Our Lady of Lourdes Medical Center in Camden (4.46 percent) and the UMDNJ-University Medical Center in Newark (6.84 percent) had rates that were significantly worse than the statewide average.

* Englewood Hospital and Medical Center had no deaths among its 102 patients, but the rate was not statistically significantly different from the state average.

* The statewide average patient stay in the hospital was 6.43 days, with individual hospitals ranging from 5.64 to 7.39 days.

Jersey City Medical Center received its cardiac surgery license in late 2004 and will be included in the next report.

The 49 surgeons named in the report had performed at least 100 bypass operations in one hospital in the years 2003-2004 combined. That is the minimum number needed to calculate reliable risk-adjusted mortality rates. Surgeon findings include:

* Three surgeons had a statistically significantly better-than-average performance – one each at Hackensack University Medical Center, AtlantiCare Regional Medical Center and St. Michael's Medical Center.

* Three had worse than average performances – one each at Cooper Hospital/University Medical Center, Our Lady of Lourdes Medical Center and PBI Regional Medical Center.

* One surgeon each at Englewood Hospital and Medical Center and Newark Beth Israel Medical Center had no deaths, although this was not statistically significantly different from the statewide average.

Four other states report on cardiac surgery outcomes. Pennsylvania and Massachusetts also examine 30-day mortality, while New York and California look at in-hospital deaths.

FDA Warns on Chinese-Manufactured Toothpaste

FDA Warns on Chinese-Manufactured Toothpaste

The FDA is warning consumers to throw out any Chinese toothpaste after it found a component of antifreeze in several products.

Because diethylene glycol (DEG) is not always listed in the ingredients on the package, the FDA says people should examine their toothpaste and discard any imported from China. So far there have been no reports of injuries from DEG-contaminated toothpaste, but there have been deaths in several countries from DEG-contaminated products like cough syrup. The FDA is concerned about chronic exposure to DEG, particularly to vulnerable populations like children and people with kidney or liver disease.

The following brands are affected by the advisory: Cooldent Fluoride, Cooldent Spearmint, Cooldent ICE, Dr. Cool, Everfresh, Superdent, Clean Rite, Oralmax Extreme, Oral Bright Fresh Spearmint Flavor, Bright Max Peppermint Flavor, ShiR Fresh Mint Fluoride Paste, DentaPro, DentaKleen, and DentaKleen Junior.

FDA advisory (Free)