Health Affairs: Specialty cardiac hospitals see better outcomes, but why?

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While cardiac specialty hospitals have been shown to have lower mortality rates, why remains unknown. In a recent study, researchers found that when physicians split caseloads overall outcomes did not significantly differ by hospital type. They concluded that data reported by physician-owned cardiac hospitals should incorporate high rates of poor outcomes for procedures done by their own cardiologists at nearby hospitals.

“Cardiac specialty hospitals—those hospitals in which 45 percent or more of the patients receive cardiac care—have been highly successful at marketing their services to consumers and have scored well on patient satisfaction surveys,” wrote Liam O’Neill, PhD, and Arthur J. Hartz, PhD, of the University of North Texas Health Science Center in Fort Worth, Texas, and of the University of Utah in Salt Lake City, respectively. “Their patients typically enjoy first-class amenities, such as private rooms, valet parking, wireless internet access, flat-screen TVs and gourmet meals. Websites of cardiac hospitals generally claim to have exceptionally good quality relative to general hospitals, along with access to the latest technology.”

Do cardiac hospitals have lower mortality rates than general hospitals? This was one question the researchers set out to answer with the study that included 210,135 patients undergoing PCI in Texas between 2004 and 2007. The results were published in the April issue of Health Affairs.

“Proponents of cardiac hospitals argue that this quality differential can be attributed to various factors, including physicians who are more skilled at delivering cardiac care, better technology, more nurses per bed, lower infection rates and greater organizational learning,” the researchers noted. “However, there is no empirical evidence supporting most of these claims.”

For the study, O’Neill and Hartz examined data from six cardiac hospitals and 18 general hospitals in six metro areas throughout Texas. All of the hospitals had physicians who performed procedures at both the cardiac hospitals and general hospitals. The researchers compared quality and organizational structures and characteristics of hospitals and then restricted the sample to include only procedures done by specialty physicians.

Cardiac hospitals included in the study saw fewer members of racial and minority groups and fewer uninsured patients and Medicare beneficiaries. Patients treated at these hospitals also had a shorter length of stay, fewer emergency admissions, more procedures and more referrals.

Cardiac hospitals also saw lower mortality rates. And while the researchers found that results for patients age 65 and older were similar, racial and ethnic minorities were less likely to have been treated at cardiac hospitals.

The researchers reported that when procedures were performed by specialty physicians in cardiac hospitals, mortality rates were lower than the state average (0.68 percent vs. 1.5 percent). Additionally, those who performed these procedures at general hospitals saw higher mortality rates when compared with the state rates (2.27 percent vs. 1.5 percent).

Unadjusted mortality rates for all PCI procedures performed by specialty physicians, regardless of where performed, was 0.85 percent. When the researchers adjusted for the patient’s condition and caseload, mortality was reported to be 1.27 percent. Risk-adjusted mortality rates for specialty physicians and high-volume cardiologists did not statistically differ.

“It is therefore likely that both lower patient acuity and higher procedural volumes contributed to cardiac hospitals’ better outcomes,” the authors wrote.

“The interaction effect was weakest (although still significant) for cardiologists who performed fewer than half of their procedures at a cardiac hospital,” the authors wrote. “This may be because these cardiologists are not hospital owners or because for other reasons they have a limited ability to steer low-risk patients to the cardiac hospital.”

The researchers noted that one potential cause of these differences in outcomes could be hospital location. Cardiac hospitals could be located in more affluent neighborhoods, for example, the authors noted. However, in three of the examined studies, cardiac hospitals and general hospitals were 0.2 miles away from each other and two had sky bridges connecting them; therefore, the authors said that hospital location may not be able to explain the differences in outcomes.

“One interpretation of these results is that physicians steer the most profitable patients to the hospitals in which they have a financial interest,” the authors noted. “As a side benefit, these hospitals have outstanding risk-adjusted mortality rates, which allow them to claim in their promotional materials that they provide exceptional quality relative to community hospitals and even to win national quality awards."

Due to the Patient Protection and Affordable Care Act (PPACA), physician-owned specialty hospitals have been struggling and some have closed. “Although the Affordable Care Act of 2010 has strictly limited the growth of physician-owned specialty hospitals, the controversy surrounding these facilities is unlikely to subside anytime soon,” the authors summed.