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50 TOP CARDIOVASCULAR HOSPITALS

12TH EDITION NOVEMBER 15, 2010

Thomson Reuters 777 E. Eisenhower Parkway Ann Arbor, MI 48108 USA +1 800 366 7526 Thomson Reuters 50 Top Cardiovascular Hospitals, 2011 Study Thomson Reuters 100 Top Hospitals is a registered trademark of Thomson Reuters. ÂŠ2010 Thomson Reuters All rights reserved. Printed and bound in the United States of America The information contained in this publication is intended to serve as a guide for general comparisons and evaluations, but not as the sole basis upon which any specific conduct is to be recommended or undertaken. The reader bears sole risk and responsibility for any analysis, interpretation, or conclusion based on the information contained in this publication, and Thomson Reuters shall not be responsible for any errors, misstatements, inaccuracies, or omissions contained herein. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from Thomson Reuters. ISBN 978-1-57372-454-8

CONTENTS

INTRODUCTION

1–2 Creating a Better Study..........................................................................................2 About Thomson Reuters........................................................................................2

50 TOP CARDIOVASCULAR HOSPITALS, 2011 AWARD WINNERS

3–4

Teaching Hospitals With Cardiovascular Residency Programs...........................3 Teaching Hospitals Without Cardiovascular Residency Programs......................4 Community Hospitals............................................................................................4 FINDINGS

5–12 How the Winners Are Outperforming Their Peers........................................... 5–9 Cardiovascular Care Has Improved With Adherence to Core Measures...... 10–12

METHODOLOGY

13–24 Overview............................................................................................................... 13 Building the Database of Hospitals................................................................13–16 Classifying Hospitals Into Comparison Groups.............................................16–17 Scoring Hospitals on Weighted Performance Measures.............................. 17–22 Determining the 50 Top Cardiovascular Hospitals...................................... 23–24

WINNERS THROUGH THE YEARS

25–37

APPENDIX: METHODOLOGY DETAILS

39–43

Methods for Identifying Complications of Care............................................ 39-41 Core Measures..................................................................................................... 42 Length of Stay and Cost per Case Methodologies.......................................42–43 Performance Measure Normalization.................................................................43 Why We Have Not Calculated Percent Change in Specific Instances................43 REFERENCES

45–46

INTRODUCTION Cardiovascular disease is the longstanding number-one killer in the United States. In fact, nearly 2,300 Americans die of cardiovascular disease each day. And with 2010 total hospital costs of $155.7 billion, it is the most expensive condition hospitals treat.1 These facts make cardiovascular services among the highest profile of all hospital service lines, with more than 1,000 hospitals performing open-heart surgery and thousands more offering medical cardiovascular programs. With these volumes, hospitals must do all they can to provide high-quality cardiovascular care as efficiently as possible. To improve performance, cardiovascular hospital leaders need objective information about what is achievable — relevant benchmarks that allow them to compare their performance to peers and the top-performing organizations. By naming the 50 Top Cardiovascular Hospitals in the nation, the Thomson Reuters 100 Top Hospitals® program provides hospital executives, physicians, and cardiovascular service line managers with valuable, practical targets for raising performance. Information in this study abstract, and available in separate facility-specific reports, provides targets to reach for, with detailed analysis of how the winners and their nonwinning peers performed on the study’s balanced scorecard of measures.

• More than 7,500 additional lives could be saved. • Nearly 12,000 additional patients could be complication-free. • Approximately $910 million could be saved.

Now in its 12th year, the 50 Top Cardiovascular Hospitals study identifies hospitals that achieve the best performance on the scorecard of performance measures. This is the 12th consecutive year that we’ve released the study. We’ve updated the year of the cardiovascular study to 2011 (the 11th edition was called the 2009 study) to match the calendar year that hospitals will be using this report and data. This year, based on comparisons between the study winners and a peer group of similar high-volume hospitals that were not winners, we found that if all cardiovascular providers performed at the level of this year’s winners:

Additionally, by analyzing data from several years of this study, we found:

We based this analysis on the Medicare patients in this study. If the same standards were applied to all inpatients, the impact would be even greater. The winning hospitals also: • Spend an average $1,300 less per case. • Have significantly better 30-day survival. • Maintain lower 30-day readmission rates for heart attack and heart patients. • Return patients to daily life half a day earlier, on average. • Are more likely to follow recommended care protocol.

• The typical hospital in our study (winners and nonwinners) has made positive changes in surgical technique: the percentage of bypass surgery patients who received an internal mammary artery (the method with proven better outcomes) has increased substantially, from 67 percent in 1999 to 92 percent in 2009. Survival rates for cardiovascular surgery patients has also increased substantially.

50 Top Cardiovascular Hospitals 1

• There have been consistent increases in the percentage of patients receiving the care recommended by core measures, suggesting that basic heart care has improved since core measures were implemented. Although all hospitals are doing a better job following these processes of care, the study winners are doing the best on core measure scores. For more details, including complete hospital reporting data on this year’s cardiovascular winning hospitals, please see the Findings section of this document.

Why did we lower the number of winners? The level of cardiovascular care has improved significantly across the industry over the last 10 years. Competition has increased, and the top providers have become a more elite group. Therefore, to better highlight those providers that are truly leading the way, we are naming only 50 winners.

CREATING A BETTER STUDY

ABOUT THOMSON REUTERS

Throughout the 18 years of the 100 Top Hospitals® program, we have worked to ensure that the measures and methodology we use are fair, consistent, and telling. We continually test the validity of our performance measures and data sources. To enhance the study this year, we have:

Thomson Reuters is the world’s leading source of intelligent information for businesses and professionals. We combine industry expertise with innovative technology to deliver critical information to leading decision makers in the financial, legal, tax and accounting, healthcare and science, and media markets, powered by the world’s most trusted news organization. With headquarters in New York and major operations in London and Eagan, Minnesota, Thomson Reuters employs more than 50,000 people and operates in over 100 countries. Thomson Reuters shares are listed on the Toronto Stock Exchange (TSX: TRI) and New York Stock Exchange (NYSE: TRI). For more information, go to thomsonreuters.com.

• Improved our ability to directly measure clinical quality by using a broader patient complications index and adding 30-day mortality and 30-day readmission measures. • Accounted for patient conditions that were present on admission in our length of stay and cost severity adjustment models. • Streamlined the number of winners from 100 to 50.

2 Thomson Reuters

As a part of our own internal performanceimprovement process, we welcome comments from hospitals and physicians. To submit comments, visit 100tophospitals.com and click Contact Us.

50 TOP CARDIOVASCULAR HOSPITALS, 2011 AWARD WINNERS Thomson Reuters is proud to present the 50 Top Cardiovascular Hospitals, 2011*, listed on the following pages. We stratify winners by three separate peer groups: Teaching Hospitals With Cardiovascular Residency Programs, Teaching

Hospitals Without Cardiovascular Residency Programs, and Community Hospitals. For full details on these peer groups and the process we use to select the benchmark hospitals, please see the Methodology section of this document.

Teaching Hospitals With Cardiovascular Residency Programs† MEDICARE ID

HOSPITAL

LOCATION

030103

Mayo Clinic Hospital

Phoenix, AZ

100289

Cleveland Clinic Florida

Weston, FL

150084

St. Vincent Indianapolis Hospital

Indianapolis, IN

170040

The University of Kansas Hospital

Kansas City, KS

190036

Ochsner Medical Center

New Orleans, LA

220077

Baystate Medical Center

Springfield, MA

230019

Providence Hospital and Medical Center

Southfield, MI

230029

St. Joseph Mercy Oakland

Pontiac, MI

230195

St. John Macomb–Oakland Hospital

Warren, MI

240010

Mayo Clinic – Saint Marys Hospital

Rochester, MN

330013

Albany Medical Center

Albany, NY

360079

Kettering Medical Center

Kettering, OH

390006

Geisinger Medical Center

Danville, PA

390079

Robert Packer Hospital

Sayre, PA

490009

University of Virginia Medical Center

Charlottesville, VA

* This is the 12th consecutive year that we’ve released the study. We’ve updated the year of the cardiovascular study to 2011

(the 11th edition was called the 2009 study) to match the calendar year that hospitals will be using this report and data. †Order of hospitals does not reflect performance rating. Hospitals are ordered by Medicare ID. 50 Top Cardiovascular Hospitals 3

Teaching Hospitals Without Cardiovascular Residency Programs† MEDICARE ID

HOSPITAL

LOCATION

030006

Tucson Medical Center

Tucson, AZ

050231

Pomona Valley Hospital Medical Center

Pomona, CA

060014

Presbyterian/St. Luke's Medical Center

Denver, CO

100080

JFK Medical Center

Atlantis, FL

100127

Morton Plant Hospital

Clearwater, FL

130006

St. Luke's Boise Medical Center

Boise, ID

130007

Saint Alphonsus Regional Medical Center

Boise, ID

160033

Genesis Medical Center East

Davenport, IA

230054

Marquette General Hospital

Marquette, MI

230097

Munson Medical Center

Traverse City, MI

240053

Park Nicolett Methodist Hospital

St. Louis Park, MN

330153

Ellis Hospital

Schenectady, NY

360035

Mount Carmel

Columbus, OH

360084

Aultman Hospital

Canton, OH

360123

St. John Medical Center

Westlake, OH

370091

Saint Francis Hospital

Tulsa, OK

390063

Hamot Medical Center

Erie, PA

440017

Wellmont Holston Valley Medical Center

Kingsport, TN

490021

Centra Health

Lynchburg, VA

490059

St. Mary's Hospital

Richmond, VA

MEDICARE ID

HOSPITAL

LOCATION

050353

Providence Little Company of Mary Medical Center

Torrance, CA

100044

Martin Memorial Medical Center

Stuart, FL

100070

Venice Regional Medical Center

Venice, FL

100258

Delray Medical Center

Delray Beach, FL

140231

Edward Hospital

Naperville, IL

140288

Advocate Good Samaritan Hospital

Downers Grove, IL

180011

Saint Joseph–London

London, KY

180130

Baptist Hospital East

Louisville, KY

340004

High Point Regional Health System

High Point, NC

360056

Mercy Hospital Fairfield

Fairfield, OH

390045

Williamsport Regional Medical Center

Williamsport, PA

430095

Avera Heart Hospital of South Dakota

Sioux Falls, SD

460021

Dixie Regional Medical Center

St. George, UT

490069

Memorial Regional Medical Center

Mechanicsville, VA

520193

Aurora BayCare Medical Center

Green Bay, WI

Community Hospitals†

†Order of hospitals does not reflect performance rating. Hospitals are ordered by Medicare ID. 4 Thomson Reuters

FINDINGS One of the goals of the 100 Top Hospitals program is to present the metrics achieved by winners as true benchmarks for the industry — to share what they do differently, highlight what makes them so successful, and offer models for other hospitals to emulate. This year, we found: • This study’s winners provide measurably better care and are more efficient than their peers. Based on comparisons between the study winners and a peer group of hospitals treating the same types of patients, we found that if all cardiovascular providers performed at the level of this year’s winners, more than 7,500 additional lives could be saved, nearly 12,000 additional patients could be complication-free, and approximately $910 million could be saved. We based this analysis on the Medicare patients included in this study. If the same standards were applied to all inpatients, the impact would be even greater. • Patients at these hospitals also enjoy better longer-term outcomes, with a better chance for survival after 30 days and a lower chance of being readmitted in that time. • The winning hospitals are more efficient, releasing patients an average of half a day sooner for an average of $1,300 less per case. Reviewing trends over several years of the cardiovascular study, we found: • The typical hospital in our study (winners and nonwinners) has made positive changes in surgical technique: the percentage of bypass surgery patients who received an internal mammary artery (the method with proven better outcomes) has increased substantially, from 67 percent in 1999 to 92 percent in 2009. Survival rates for cardiovascular surgery patients has also increased substantially.

• Consistent increases in the percentage of patients receiving care recommended by the core measures, suggesting that basic heart care has improved since core measures were implemented. Although it appears that many hospitals are improving in their use of these measures, our cardiovascular study winners are still ahead of nonwinners. • The winning hospitals not only perform better on the measures used in the study, but also on other care protocol — in particular, two surgical core measures that relate to beta blocker use and glucose control. Not following through on these measures has been related to higher mortality. HOW THE WINNERS ARE OUTPERFORMING THEIR PEERS

All Study Hospitals Over the last several years, all U.S. hospitals have improved outcomes for cardiovascular patients. Survival rates are increasing and serious complications are less frequent. In fact, this study shows that at both winning and nonwinning hospitals 96 percent of cardiovascular patients who receive inpatient care are surviving, and approximately 93 percent are complication-free. The smaller, more elite group of winners in this year’s cardiovascular study provide some actionable benchmarks for all hospitals providing cardiovascular services. In addition to providing superior care, saving more lives, avoiding complications and readmission, the winning hospitals are also more efficient.

50 Top Cardiovascular Hospitals 5

Survival rates are markedly better at benchmark (winning) hospitals, particularly for patients receiving bypass surgery and angioplasties (CABGs and PCIs). The median benchmark hospital had a risk-adjusted CABG mortality index of 0.63, meaning they experienced 37 percent fewer deaths than would be expected. Peer (nonwinning) hospitals, on the other hand, had only 4 percent fewer CABG mortalities than expected. Longer-term survival rates were also better at winning hospitals, as displayed by the lower 30-day heart failure and heart attack mortality.

had only 2 percent fewer heart failure patient complications than expected. Lower complications could be helping the winning hospitals have a lower percentage of patients readmitted after 30 days. Winning hospitals appear to comply with measures protocols more closely. With a median heart failure core measures score of 97 percent, we know that this year’s winners are using the recommended core measures protocol for 97 percent of their heart failure patients, while the peer hospitals are using the measures for only 95 percent. Differences are just slightly lower for heart attack patients (Table 1).

Reducing patient complications is an ongoing goal for all hospitals targeting improved performance. The cardiovascular study winners had a substantially lower complications index than their peers. Most notably was the heart failure complications index at winning hospitals, which was 23 percent lower than expected. Peer hospitals, on the other hand,

Not only are winning hospitals providing superior cardiovascular care, they are also more efficient. The winners achieve better clinical outcomes, while discharging patients half a day sooner and spending nearly $1,300 less per case.

TABLE 1: All Hospitals In Study, Benchmark versus Peer Performance Comparisons PERFORMANCE MEASURE

CLINICAL OUTCOME MEASURES1,2

EXTENDED OUTCOME MEASURES4

EFFECIENCY MEASURES

DIFFERENCE

PERCENT DIFFERENCE

BENCHMARK HOSPITALS OUTPERFORM PEER HOSPITALS

0.84

1.00

-0.16

-16.0

lower mortality

HF Mortality

0.82

0.98

-0.16

-16.3

lower mortality

CABG Mortality

0.63

0.96

-0.33

-34.4

lower mortality

PCI Mortality

0.74

0.97

-0.23

-23.7

lower mortality

AMI Complications

0.80

0.94

-0.14

-14.9

fewer complications

HF Complications

0.77

0.98

-0.21

-21.4

fewer complications

CABG Complications

0.88

0.99

-0.11

-11.1

fewer complications

PCI Complications

0.92

0.97

-0.05

-5.2

fewer complications

Heart Attack Core Measures Mean Percent3

98.0

96.8

1.2

n/a5

better performance

Heart Failure Core Measures Mean Percent3

97.4

95.3

2.1

n/a5

better performance

CABG Patients With Internal Mammary Artery Use (%)

95.7

92.2

3.6

n/a5

higher IMA use

AMI 30-Day Mortality (%)

14.4

15.7

-1.4

n/a5

lower 30-day mortality

HF 30-Day Mortality (%)

10.6

10.8

-0.3

n/a5

lower 30-day mortality

AMI 30-Day Readmissions (%)

19.5

19.8

-0.4

n/a5

lower 30-day readmissions

HF 30-Day Readmissions (%)

23.7

24.3

-0.6

n/a5

lower 30-day readmissions

5.3

5.8

-0.5

-7.8

shorter ALOS

16,162

17,453

-1,291

-7.4

lower cost per case

Severity-Adjusted Average Length of Stay (days) Wage- and Severity-Adjusted Average Cost per Case ($)

1 MedPAR 2008 and 2009, combined. 2 Ratings greater than 1.0 exceed national norms; ratings less than 1.0 fall below national norms. 3 CMS Hospital Compare 2008Q4–2009Q1,Q2,Q3. 4 CMS Hospital Compare July 1, 2006–June 30, 2009. 5 We do not calculate percentage difference for measures already expressed as a percent.

6 Thomson Reuters

PEER MEDIAN

AMI Mortality

Risk-Adjusted Medical Mortality Index

Risk-Adjusted Complications Index

CLINICAL PROCESS MEASURES

BENCHMARK MEDIAN

Teaching Hospitals With Cardiovascular Residency Programs Benchmark teaching hospitals with cardiovascular residency programs had risk-adjusted mortality indices that were significantly lower than their peers, particularly for the surgery patient groups we studied (CABG and PCI). A 0.64 CABG mortality index for the median benchmark hospital in this group means they had 36 percent fewer deaths than would be expected. This is a markedly better outcome than that experienced by the peer hospitals in this group, which, with an index of 0.99, had 1 percent fewer mortalities than expected, given their patients’ risk. Differences in benchmark and peer PCI mortality rates were similar. Benchmark hospitals in this group were much more successful than their peers at avoiding patient complications in cardiology patients. Their risk-adjusted rate for

this measure showed they had 24 percent fewer HF patient complications than expected, whereas their peers had only 1 percent fewer than expected (Table 2). AMI and CABG results were similar. Winning hospitals in this category also had significantly lower AMI 30-day mortality rates, and had fewer patients return to the hospital within 30 days than their peers. Teaching hospitals with residency programs generally treat more complex patients and have more sophisticated personnel mixes and higher input costs than community hospitals and those without cardiovascular residency programs. As such, they must work hard to keep costs in check. The typical benchmark hospital in this group managed to spend $1,100 less per case than the typical peer hospital and was able to release the typical patient two-thirds of a day sooner.

TABLE 2: Teaching Hospitals With Cardiovascular Residency Programs, Benchmark Versus Peer Performance Comparisons PERFORMANCE MEASURE

CLINICAL OUTCOME MEASURES1,2

Risk-Adjusted Medical Mortality Index

Risk-Adjusted Complications Index

EXTENDED OUTCOME MEASURES4

EFFECIENCY MEASURES

PEER MEDIAN

DIFFERENCE

BENCHMARK HOSPITALS OUTPERFORM PEER HOSPITALS

PERCENT DIFFERENCE

AMI Mortality

0.84

1.01

-0.17

-16.8

lower mortality

HF Mortality

0.83

0.99

-0.16

-16.2

lower mortality

CABG Mortality

0.64

0.99

-0.35

-35.4

lower mortality

PCI Mortality

0.68

0.99

-0.31

-31.3

lower mortality

AMI Complications

0.80

0.97

-0.17

-17.5

fewer complications

HF Complications

0.76

0.99

-0.23

-23.2

fewer complications

CABG Complications

0.79

1.01

-0.22

-21.8

fewer complications

PCI Complications CLINICAL PROCESS MEASURES

BENCHMARK MEDIAN

0.91

0.98

-0.07

-7.1

fewer complications

Heart Attack Core Measures Mean Percent3

97.8

96.8

1.0

n/a5

better performance

Heart Failure Core Measures Mean Percent3

96.8

95.5

1.3

n/a5

better performance

CABG Patients With Internal Mammary Artery Use (%)

96.2

92.8

3.4

n/a5

higher IMA use

AMI 30-Day Mortality (%)

13.7

15.2

-1.5

n/a5

lower 30-day mortality

HF 30-Day Mortality (%)

10.0

0.0

n/a5

lower 30-day mortality

AMI 30-Day Readmissions (%)

19.8

20.5

-0.7

n/a5

lower 30-day readmissions

HF 30-Day Readmissions (%)

24.5

25.2

-0.6

n/a5

lower 30-day readmissions

5.2

5.8

-0.6

-10.2

shorter ALOS

16,878

17,981

-1,103

-6.1

Severity-Adjusted Average Length of Stay (days) Wage- and Severity-Adjusted Average Cost per Case ($)

lower cost per case

50 Top Cardiovascular Hospitals 7

50 Top Teaching Hospitals Without Cardiovascular Residency Programs The winning hospitals in this category show the greatest strength/achievement at adhering to recommended clinical processes, such as core measures and the use of internal mammary arteries in bypass surgeries, especially compared with their peers. Their core measure scores for heart attack and heart failure patients were 97.8 and 97.5, respectively, meaning that these hospitals are using the recommended core measures protocol for nearly 98 percent of their AMI and HF patients.

Benchmark teaching hospitals without cardiovascular residency programs had a riskadjusted mortality for CABG patients that was about 30 percent lower than their peers. A 0.68 CABG mortality index for the median benchmark hospital in this group means they had 32 percent fewer deaths than would be expected. This is a markedly better outcome than that experienced by the peer hospitals in this group, who, with an index of 0.97, had only 3 percent fewer CABG mortalities than expected. These hospitals also had a relatively low complications index, especially compared with their peers (Table 3).

TABLE 3: Teaching Hospitals Without Cardiovascular Residency Programs, Benchmark Versus Peer Performance Comparisons PERFORMANCE MEASURE

CLINICAL OUTCOME MEASURES1,2

Risk-Adjusted Medical Mortality Index

Risk-Adjusted Complications Index

CLINICAL PROCESS MEASURES

EXTENDED OUTCOME MEASURES4

DIFFERENCE

PERCENT DIFFERENCE

BENCHMARK HOSPITALS OUTPERFORM PEER HOSPITALS

0.86

1.01

-0.15

-14.9

lower mortality

HF Mortality

0.82

0.99

-0.17

-17.2

lower mortality

CABG Mortality

0.68

0.97

-0.29

-29.9

lower mortality

PCI Mortality

0.86

0.99

-0.13

-13.1

lower mortality

AMI Complications

0.85

0.95

-0.10

-10.5

fewer complications

HF Complications

0.88

0.98

-0.10

-10.2

fewer complications

CABG Complications

0.88

1.00

-0.12

-12.0

fewer complications

PCI Complications

0.96

0.97

-0.01

-1.0

fewer complications

Heart Attack Core Measures Mean Percent3

97.8

96.5

1.3

n/a5

better performance

Heart Failure Core Measures Mean Percent3

97.5

95.3

2.3

n/a5

better performance

CABG Patients With Internal Mammary Artery Use (%)

96.5

92.1

4.3

n/a5

higher IMA use

AMI 30-Day Mortality (%)

15.0

15.6

-0.6

n/a5

lower 30-day mortality

HF 30-Day Mortality (%)

10.7

11.0

-0.3

n/a5

lower 30-day mortality

AMI 30-Day Readmissions (%)

19.6

0.0

n/a5

lower 30-day readmissions lower 30-day readmissions shorter ALOS

Severity-Adjusted Average Length of Stay (days) Wage- and Severity-Adjusted Average Cost per Case ($)

22.9

23.9

-1.0

n/a5

5.4

5.8

-0.4

-6.9

15,881

17,199

-1,318

-7.7

1 MedPAR 2008 and 2009, combined. 2 Ratings greater than 1.0 exceed national norms; ratings less than 1.0 fall below national norms. 3 CMS Hospital Compare 2008Q4â&#x20AC;&#x201C;2009Q1,Q2,Q3. 4 CMS Hospital Compare July 1, 2006â&#x20AC;&#x201C;June 30, 2009. 5 We do not calculate percentage difference for measures already expressed as a percent.

8 Thomson Reuters

PEER MEDIAN

AMI Mortality

HF 30-Day Readmissions (%) EFFECIENCY MEASURES

BENCHMARK MEDIAN

lower cost per case

Benchmark Community Hospitals The benchmark community hospitals had the lowest surgical and medical mortality rates of all the comparison groups we studied, with 42 percent fewer CABG mortalities than expected and approximately 47 percent fewer PCI deaths than expected (Table 4).

This group also performed particularly well in avoiding complications for medical (AMI and HF) heart patients. For both patient groups, the winning hospitals had 30 percent fewer patient complications than expected.

TABLE 4: Community Hospitals, Benchmark Versus Peer Performance Comparisons PERFORMANCE MEASURE

CLINICAL OUTCOME MEASURES1,2

EXTENDED OUTCOME MEASURES4

EFFECIENCY MEASURES

PEER MEDIAN

DIFFERENCE

BENCHMARK HOSPITALS OUTPERFORM PEER HOSPITALS

PERCENT DIFFERENCE

AMI Mortality

0.79

1.00

-0.21

-21.0

lower mortality

HF Mortality

0.78

0.98

-0.20

-20.4

lower mortality

CABG Mortality

0.58

0.93

-0.35

-37.6

lower mortality

PCI Mortality

0.53

0.96

-0.43

-44.8

lower mortality

AMI Complications

0.70

0.93

-0.23

-24.7

fewer complications

HF Complications

0.70

0.97

-0.27

-27.8

fewer complications

CABG Complications

0.90

0.99

-0.09

-9.1

fewer complications

PCI Complications

0.90

0.95

-0.05

-5.3

fewer complications

Heart Attack Core Measures Mean Percent3

98.5

96.8

1.7

n/a5

better performance

Heart Failure Core Measures Mean Percent3

97.5

95.4

2.1

n/a5

better performance

CABG Patients With Internal Mammary Artery Use (%)

94.9

92.1

2.9

n/a5

higher IMA use

AMI 30-Day Mortality (%)

14.8

15.8

-1.0

n/a5

lower 30-day mortality

HF 30-Day Mortality (%)

10.3

11.0

-0.7

n/a5

lower 30-day mortality

AMI 30-Day Readmissions (%)

18.9

19.7

-0.8

n/a5

lower 30-day readmissions

HF 30-Day Readmissions (%)

23.7

24.3

-0.6

n/a5

lower 30-day readmissions

5.5

5.8

-0.3

-5.0

shorter ALOS

15,882

17,432

-1,550

-8.9

lower cost per case

Risk-Adjusted Medical Mortality Index

Risk-Adjusted Complications Index

CLINICAL PROCESS MEASURES

BENCHMARK MEDIAN

Severity-Adjusted Average Length of Stay (days) Wage- and Severity-Adjusted Average Cost per Case ($)

50 Top Cardiovascular Hospitals 9

CARDIOVASCULAR CARE HAS IMPROVED WITH ADHERENCE TO CORE MEASURES

The cardiovascular study includes core measures used for heart failure and heart attack patients. (Please see the Methodology section and Appendix for details on our core measures calculation and a list of measures included.). Although evaluating core measure use does not directly measure outcomes, evaluating it is important; adherence to some has been shown to lead to better survival of hospital patients.2,3 Our research for this study included a more indepth look at the cardiovascular core measures and found that consistent increases in adherence to core measures show us that basic heart care has improved since core measures were implemented. This shows that public reporting of cardiovascular core measures has led to better care over time. All hospitals are improving, but our cardiovascular study winners are still ahead of nonwinners.

Between 2007 and 2010, cardiovascular study winners improved their heart failure core measure performance by about 8 percentage points, to 97 percent, meaning the measures were complied with for an average of 97 percent of the patients who were eligible for them. Nonwinning hospitals showed a greater increase in improvement during that time â&#x20AC;&#x201D; moving up by nearly 12 percentage points, to a 2010 figure of 94 percent (Figure 1). We found a similar trend for heart attack core measures, with winners having higher compliance than nonwinners, but both groups showing an increase between 2007 and 2010. Compared with the heart failure core measure trend, improvement in heart attack core measure scores is not as great â&#x20AC;&#x201D; about 4 percentage points for winning hospitals and 6 percentage points for nonwinners (Figure 2).

FIGURE 1: Trends in Heart Failure Core Measure Performance, Winners Versus Nonwinners 100%

Percent Adherence

95%

90%

85%

80%

75% 2007 Winner

10 Thomson Reuters

2008 Nonwinner

2009

2010

FIGURE 2: Trends in Heart Attack Core Measure Performance, Winners Versus Nonwinners 100%

Percent Adherence

95%

90%

85%

80%

75% 2007 Winner

2008

2009

2010

Nonwinner

We also analyzed the performance of winner and nonwinner hospitals on two surgical core measures that were not used in this year’s 50 Top Cardiovascular Study selection process: “cardiac surgery patients with controlled 6:00 a.m. post-op blood glucose” and “beta blocker in perioperative period for surgical patients who were on beta blockers prior to admission.” The glucose measure’s goal is for a cardiac surgery patient’s blood glucose to be controlled at 6:00 a.m. for the two days after surgery. The beta blocker measure aims for patients who take beta blockers to continue medication from before surgery through discharge from the recovery area.

A number of studies have associated elevated blood glucose following heart surgery with increased inhospital morbidity, particularly infections, as well as increased inhospital mortality.4–8 Continuation of beta blocker use in the perioperative period has been associated with lower mortality at one year.9–13 Both are measures developed in the Surgical Care Improvement Project (SCIP), which involves a partnership of a number of organizations interested in reducing surgical complications. Winning hospitals achieved the glucose core measure on 95 percent of eligible patients, while nonwinners used it on just 92 percent (Figure 3). For the beta blocker measure, winning hospitals had 93 percent adherence, compared with just 90 percent for nonwinners. Both findings were statistically significant.

50 Top Cardiovascular Hospitals 11

FIGURE 3: Selected Surgical Care Core Measures, Winners Versus Nonwinners 96%

Winner Nonwinner

95%

Percent Adherence

94% 93% 92% 91% 90% 89% 88%

Glucose Control

Beta Blocker Use

Please visit 100tophospitals.com to download a brief with full details on this research.

12 Thomson Reuters

METHODOLOGY The 50 Top Cardiovascular Hospitals is a quantitative study that uses a balanced scorecard approach, based on publicly available data, to identify the top cardiovascular hospitals in the United States. This study focuses on short-term, acutecare, nonfederal U.S. hospitals that treat a broad spectrum of cardiology patients. It includes patients requiring medical management, as well as those who receive invasive or surgical procedures. Because multiple measures are used, a hospital must provide all forms of cardiovascular care, including open-heart surgery, to be included in the study. OVERVIEW

The main steps we take in selecting the 50 cardiovascular study winners are: • Building the database of hospitals, including special selection and exclusion criteria • Classifying hospitals into comparison groups • Scoring hospitals on a set of weighted performance measures • Determining the 50 hospitals with the best performance by ranking relative to comparison group The following section is intended to be an overview of these steps. To request more detailed information on any of the study concepts outlined here, please email us at healthcare.pubs@thomsonreuters.com or call +1 800 568 3282. Note: The level of cardiovascular care has improved significantly across the industry over the last 10 years, as demonstrated by the improvements we’ve seen — better survival, fewer patient complications, and shorter hospital stays — since the study’s inception. With all cardiovascular service providers

showing a higher level of performance, competition has increased and the top providers have become a more elite group. Therefore, to better highlight those providers that are truly leading the way, we are naming only 50 winners. With a group of 50 winners, we are able to raise the bar with much higher achievable targets. If all hospitals performed like the cardiovascular study winners:

MAJOR CHANGES TO THIS YEAR’S STUDY: • Chosen a more elite group of winners. We’ve streamlined the number of winners from 100 to 50. • Enhanced our ability to directly measure clinical quality by using a broader patient complications index (in place of the previous postop infection and hemorrhage indices) and adding 30-day mortality and 30day readmission measures. • Dropped the patient volume measure, which was an indirect measure of care quality. • Accounted for present on admission (POA) data in the length of stay and cost per case.

• 7,543 more lives could be saved, • 11,751 additional patients could be complication-free, and • nearly $910 million could be saved. BUILDING THE DATABASE OF HOSPITALS

Primary Data Sources Like all 100 Top Hospitals® studies, the Cardiovascular Benchmarks study uses only publicly available data. The data primarily come from: • The Medicare Provider Analysis and Review (MedPAR) data set • The Medicare Cost Report • The Centers for Medicare and Medicaid Services (CMS) Hospital Compare data set

50 Top Cardiovascular Hospitals 13

We use MedPAR patient-level medical record information to calculate mortality, complications, and length of stay. It is also used for patient-level charge data in estimating cost per adjusted discharge. This data set contains information on the approximately 12 million Medicare patients who are discharged from the nation’s acute-care hospitals annually. We used the most recent two years of MedPAR data available, 2008 and 2009, in this study.

We used the CMS Hospital Compare data set published the second quarter of 2010 for core measures, 30-day mortality rate, and 30-day readmission rate performance measures. Finally, we use residency program information to classify teaching hospitals. This comes from the American Medical Association (for Accreditation Council for Graduate Medical Education (ACGME)-accredited programs) and the American Osteopathic Association (AOA).

To be included in the study, a hospital must have both years of data available. In 2008, CMS began requiring hospitals to report Medicare managed care (HMO) patient encounter data. Compliance was not uniform across all hospitals in the MedPAR 2008 data set.

Present on Admission Data The study’s length of stay and cost per case performance measures use Thomson Reuters propriety severity adjustment model. This model now includes present on admission (POA) data that was reported in the 2009 MedPAR data set. Under the Deficit Reduction Act of 2005, as of federal fiscal year 2008, hospitals do not receive payment for cases with certain conditions, like falls, surgical site infections, and pressure ulcers, that were not present on the patient’s admission but occur during their hospitalization. As a result, CMS now requires all inpatient prospective payment system hospitals to document whether a patient has these conditions when admitted.14

We use Medicare cost reports to create our proprietary database, which contains hospitalspecific demographic information and hospitalspecific all-payer cost and charges data. The hospital ratio of cost to charges is applied to MedPAR patient-level claims data to estimate cost for the study’s cost measures. For this study, we used 2009 cost report data to determine the ratio of cost to charges, whenever available. If 2009 data were not available, we used 2008 data. The Medicare Cost Report is filed annually by every U.S. hospital that participates in the Medicare program. Hospitals are required to submit cost reports in order to receive reimbursement from Medicare. It should be noted, however, that cost report data include services for all patients, not just Medicare beneficiaries. We and many others in the healthcare industry have used the MedPAR and Medicare Cost Report databases for many years. We believe they are accurate and reliable sources for the types of analyses performed in this study. Medicare data are highly representative of the cardiovascular patients included in this study. In fact, Medicare inpatients usually represent about two-thirds of all patients undergoing medical treatment for acute myocardial infarction (AMI) or experiencing heart failure (HF), and about half of all patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). Furthermore, many previous academic and economic studies of healthcare in the United States have been based on the assumption that Medicare data are representative of the all-payer activity at hospitals.

14 Thomson Reuters

Hospitals and Patient Groups Included The focus of the study is on hospitals that offer both medical and surgical options for patients with two of the most common cardiovascular conditions — coronary atherosclerosis, including AMI, and HF. To build such a database, we included all hospitals that had, in the 2008 and 2009 data years combined, at least 30 unique cases15 in each of the groups described below. 1. AMI patients in Medicare Severity Diagnosis Related Groups (MS-DRGs) 280–285 with the following ICD-9-CM codes as primary diagnosis only: • 410.01 Acute myocardial infarction of anterolateral wall, initial episode of care • 410.11 Acute myocardial infarction of other anterior wall, initial episode of care • 410.21 Acute myocardial infarction of inferolateral wall, initial episode of care • 410.31 Acute myocardial infarction of inferoposterior wall, initial episode of care • 410.41 Acute myocardial infarction of other inferior wall, initial episode of care • 410.51 Acute myocardial infarction of other lateral wall, initial episode of care

• 410.61 Acute myocardial infarction, true posterior wall infarction, initial episode of care • 410.71 Acute myocardial infarction, subendocardial infarction, initial episode of care • 410.81 Acute myocardial infarction of other specified sites, initial episode of care • 410.91 Acute myocardial infarction, unspecified site, initial episode of care

3. PCI patients with any (primary or secondary) of the following ICD-9-CM procedure codes: • 00.66 PTCA or coronary atherectomy • 36.06 Insertion of coronary artery stent(s) • 36.07 Insertion of drug-eluting coronary artery stent(s)

The AMI group is restricted to non-surgical patients.

Patients with the 36.06 or 36.07 codes are excluded if they also have the procedure code 36.03 (open chest coronary artery angioplasty).

2. HF patients in MS-DRGs 291-293 with the following ICD-9-CM code as primary diagnosis only:

4. CABG patients in MS-DRGs 231–236 and 293 with any (primary or secondary) of the following ICD-9-CM procedure codes:

• 398.91 Rheumatic heart failure • 402.01 Malignant hypertensive heart disease • 402.11 Benign hypertensive heart disease • 402.91 Unspecified hypertensive heart disease • 404.01 Malignant hypertensive heart and renal disease • 404.03 Malignant hypertensive heart and renal disease with renal failure • 404.11 Benign hypertensive heart and renal disease • 404.13 Benign hypertensive heart and renal disease with renal failure • 404.91 Unspecified hypertensive heart and renal disease • 404.93 Unspecified hypertensive heart and renal disease with renal failure • 428.0 Unspecified congestive heart failure • 428.1 Left heart failure • 428.20 Unspecified systolic heart failure • 428.21 Acute systolic heart failure • 428.22 Chronic systolic heart failure • 428.23 Acute on chronic systolic heart failure • 428.30 Unspecified diastolic heart failure • 428.31 Acute diastolic heart failure • 428.32 Chronic diastolic heart failure • 428.33 Acute on chronic diastolic heart failure • 428.40 Unspecified combined systolic and diastolic heart failure • 428.41 Acute combined systolic and diastolic heart failure • 428.42 Chronic combined systolic and diastolic heart failure • 428.43 Acute on chronic combined • 428.9 Unspecified heart failure

• 36.10 Aortocoronary bypass, unspecified number of arteries • 36.11 Aortocoronary bypass, one coronary artery • 36.12 Aortocoronary bypass, two coronary arteries • 36.13 Aortocoronary bypass, three coronary arteries • 36.14 Aortocoronary bypass, four or more coronary arteries • 36.15 Single internal mammary-coronary artery bypass • 36.16 Double internal mammary-coronary artery bypass • 36.17 Abdominal-coronary artery bypass • 36.19 Other bypass anastomosis for heart revascularization When a patient record has both PCI and CABG procedures, we place them into the CABG group for all performance measures. Patient Records Excluded The AMI and HF groups explicitly exclude patients who also had a PCI and/or CABG procedure (to ensure we have exclusively medical patients in these groups). Also excluded are: • Patients who were discharged to another short-term facility (this is done to avoid double-counting) • Patients who were not at least 65 years old

The HF category is restricted to non-surgical patients.

50 Top Cardiovascular Hospitals 15

Hospitals Excluded After building the database of cardiovascular hospitals, we excluded a number of hospitals that would have skewed the study results. A new exclusion has been added for hospitals not reporting POA. This was done because the Thomson Reuters proprietary length of stay and cost per case severityadjustment models now account for POA. As of 2008, CMS requires hospitals participating in Medicare to report POA data. Excluded from the study were: • Hospitals with fewer than 30 unique patient records in each patient group (AMI, HF, CABG, and PCI) for the two MedPAR years combined • Specialty hospitals, other than cardiac hospitals (e.g., critical access hospitals, children’s, women’s, psychiatric, substance abuse, rehabilitation, and long-term acute-care hospitals) • Hospitals with fewer than 25 acute-care beds • Federally owned hospitals • Non-U.S. hospitals (such as those in Puerto Rico, Guam, and the Virgin Islands) • Hospitals with Medicare average lengths of stay longer than 30 days • Hospitals with overall mortality rates (number of deaths divided by total discharges) of less than 1 percent • Hospitals that do not have both 2008 and 2009 Medicare claims • Hospitals missing data for calculation of one or more performance measures • Hospitals for which a Medicare Cost Report was not available for 2009 or 2008 • Hospitals that did not report POA information, including Maryland§ hospitals in the Medicare waiver program, because their data are not comparable to other hospitals CLASSIFYING HOSPITALS INTO COMPARISON GROUPS

Bed size, teaching status, and residency/fellowship program involvement have a profound effect on the types of patients a hospital treats and the scope of services it provides. When analyzing the performance of an individual hospital, it is crucial to evaluate it against other similar hospitals. To address this, we assigned each hospital to one of three comparison groups according to its teaching and residency program status.

Our formula for defining the cardiovascular hospital comparison groups includes each hospital’s bed size, residents-to-beds ratio, and involvement in graduate medical education (GME) programs accredited by either the Accreditation Council for Graduate Medical Education16 or the American Osteopathic Association.17 We define the groups as follows: Teaching Hospitals With Cardiovascular Residency Programs Must be involved in a cardiovascular residency program accredited by the ACGME or the AOA AND Must meet any two of the following three criteria: 5. 200 or more acute-care beds in service 6. An intern-resident-per-bed ratio of at least 0.03 7. Involvement in at least three accredited GME programs overall Cardiovascular residency programs include any of the following: • • • • • •

Cardiology Cardiothoracic surgery Cardiovascular disease Cardiovascular medicine Interventional cardiology Thoracic surgery

Clinical cardiac electrophysiology and cardiovascular radiology residency programs are not included. Teaching Hospitals Without Cardiovascular Residency Programs There is no involvement in a cardiovascular residency program. Must meet any two of the following three criteria: 1. 200 or more acute-care beds in service 2. An intern-resident-per-bed ratio of at least 0.03 3. Involvement in at least three accredited GME programs overall

§ Maryland’s hospitals are not paid under Medicare’s inpatient prospective payment system. Instead, they have a Medicare waiver agreement that

allows Medicare reimbursement according to rates set by the state’s Health Services Cost Review Commission. For more information, see http:// mhcc.maryland.gov/consumerinfo/hospitalguide/patients/other_information/overview_of_maryland_regulatory_system_for_hospital_oversight.html. 16 Thomson Reuters

Community Hospitals Must meet both of the following criteria: 1. 25 or more acute-care beds in service 2. Not classified as a teaching hospital per definitions above

Bed size and number of interns/residents (full-time equivalents) are taken from each hospitalâ&#x20AC;&#x2122;s Medicare Cost Report for the most current year available. 2011 Study Group (In-Study Cardiovascular Hospitals) The final study group, after exclusions, consisted of:

COMPARISON GROUP

TOTAL

Teaching Hospitals With Cardiovascular Residency Programs

183

Teaching Hospitals Without Cardiovascular Residency Programs

286

Community Hospitals

553

Total In-Study Hospitals

1,022

SCORING HOSPITALS ON WEIGHTED PERFORMANCE MEASURES

Evolution of Performance Measures We use a balanced scorecard approach, based on public data, to select the measures most useful for boards and CEOs in the current operating environment. Throughout the life of the study, we have worked hard to meet this vision. We gather feedback from industry leaders, hospital executives, academic leaders, and internal experts; review trends in the healthcare market; and survey hospitals in demanding marketplaces to learn

CLINICAL OUTCOME MEASURES CLINICAL PROCESS MEASURES EXTENDED OUTCOME MEASURES EFFICIENCY MEASURES

what measures are valid and reflective of top performance. As the market has changed, our methods have evolved. This evolution has led us to make a number of changes to this year's study, including the addition of a new domain of measurement: extended outcomes. All measures have a weight of one during final ranking, with the exception of the new 30-day mortality and 30-day readmission measures. The measures used in this yearâ&#x20AC;&#x2122;s study are:

RANKED PERFORMANCE METRIC

WEIGHT

1. Risk-Adjusted Mortality Index

2. Risk-Adjusted Complications Index

3. Core Measures (Heart Attack, Heart Failure)

4. Percentage of CABG Patients With Internal Mammary Artery Use

5. 30-Day Mortality (AMI, HF)

1/2

6. 30-Day Readmissions (AMI, HF)

1/2

7. Severity-Adjusted Average Length of Stay

8. Wage- and Severity-Adjusted Average Cost per Case

On the following pages, we provide a rationale for the selection of our balanced scorecard domains and the measures used for each.

50 Top Cardiovascular Hospitals 17

Clinical Excellence Clinical excellence can be measured by looking at several key domains: outcomes, process and extended outcomes. Our clinical outcome measures are the risk-adjusted mortality and risk-adjusted complications indexes for all included cardiovascular patient groups (AMI, HF, CABG, PCI). These mortality and complications measures show us how the provider is performing on the most basic and essential care standards — survival and error-free care — while treating patients in the facility. This year, we added the risk-adjusted complications measure in place of the previously used post-op infection and post-op hemorrhage complications measures. The new complications measure is far more comprehensive, including 30 possible patient complications and a much larger database of patients. Clinical process measures include heart attack and heart failure core measures, along with the percentage of CABG patients with internal mammary artery use. Core measures were developed by The Joint Commission and endorsed by the National Quality Forum as minimum process of care standards. They are a widely accepted method for measuring patient care quality that includes specific guidelines for heart attack, heart failure, pneumonia, pregnancy and related conditions, and surgical infection prevention.

18 Thomson Reuters

Our core measures score is based on the heart attack and heart failure areas of this program, using Hospital Compare data reported on the CMS Web site. The clinical advantages of using an internal mammary graft are many, and have been spelled out in numerous studies over the last two decades.18–22 The new extended outcome domain includes 30day mortality rates and 30-day readmission rates for AMI and HF patients. These measures help us understand how the hospital’s patients are faring over a longer period of time and may be an indicator of both discharge appropriateness and effectiveness of follow-up care coordination. Since these measures are part of CMS’ value-based purchasing program, they are being watched closely in the industry. Hospitals with lower values appear to be providing care with better medium-term results for these conditions. The availability of these measures of extended care quality have led us to drop the previously used procedure volume threshold measure, which was an indirect measure of quality. Service Delivery Efficiency We use severity-adjusted average length of stay and severity- and wage-adjusted cost per case as our measures of service delivery efficiency. For the life of the study, severity-adjusted average length of stay has served as a proxy for clinical efficiency and cost per case has served as a measure of both clinical and operating efficiency.

MEASURE: Risk-Adjusted Mortality Index FAVORABLE VALUES ARE

WHY WE INCLUDE THIS ELEMENT

CALCULATION

COMMENTS

While all hospitals have patient deaths, this measure shows where deaths occurred that would not have been expected, considering a patient’s medical condition.

The Risk-Adjusted Mortality Index is the number of actual deaths, divided by the number expected.

We used two years of MedPAR data (2008 and 2009) to reduce the influence of chance fluctuation. POA-enabled risk models were not used because hospitals only began reporting POA in 2009 MedPAR.

We normalize the index based on the observed and expected deaths for each comparison group and for each patient group (AMI, HF, CABG, and PCI). Expected deaths are based on our statistical model for predicting the likelihood of a patient’s death based on their medical record (age, sex, presence of complicating diagnoses, and other characteristics) and factors associated with the hospital (teaching status, geographic location, and size). See the Appendix for details. The reference value for this index is 1.00; a value of 1.15 indicates 15 percent more events than predicted, and a value of 0.85 indicates 15 percent fewer.

Lower

We based the scoring for each patient group (AMI, HF, CABG, and PCI) on the difference between observed and expected deaths, expressed in normalized standard deviation units (z-score). Normalization was done by comparison group. Hospitals with the fewest deaths, relative to the number expected, received the highest scores. Hospitals with values that were high statistical outliers, based on a normalized z-score greater than or equal to 1.64 (95 percent confidence), were not eligible to be benchmark hospitals. Each patient group under this measure received ¼ weight in the final overall ranking process.

MEASURE: Risk-Adjusted Complications Index FAVORABLE VALUES ARE

WHY WE INCLUDE THIS ELEMENT

CALCULATION

COMMENT

Keeping patients free from potentially avoidable complications is an important goal for all healthcare providers. A lower complications index indicates fewer patients with complications, considering what would be expected based on patient characteristics. Like the mortality index, this measure can show where complications did not occur but were expected, or the reverse, given the patient's condition.

We calculate an index value based on the number of cases with complications in 2008 and 2009, combined, divided by the number expected, given the risk of complications for each patient.

We used two years of MedPAR data (2008 and 2009) to reduce the influence of chance fluctuation. POA-enabled risk models were not used because hospitals only began reporting POA in 2009 MedPAR.

We normalize the index based on the observed and expected complications for each comparison group and for each patient group (AMI, HF, CABG, and PCI). This measure uses our proprietary expected complications rate index models. These models account for patientlevel characteristics (age, sex, principal diagnosis, comorbid conditions, and other characteristics), as well as differences in hospital characteristics (size, teaching status, geographic location, and community setting). Complication rates are calculated from normative data for two patient risk groups: medical and surgical. For more details on the model, see the Appendix.

We based the scoring for each patient group (AMI, HF, CABG, and PCI) on the difference between the observed and expected number of patients with complications, expressed in normalized standard deviation units (z-score). Normalization was done by comparison group and patient group (AMI and HF). Hospitals with the fewest observed complications, relative to the number expected, after accounting for standard binomial variability, received the most favorable scores. Hospitals with values that were high statistical outliers, based on a normalized z-score greater than or equal to 1.64 (95 percent confidence), were not eligible to be benchmark hospitals.

The reference value for this index is 1.00; a value of 1.15 indicates 15 percent more complications occurred than were predicted, and a value of 0.85 indicates 15 percent fewer complications than predicted.

Each patient group under this measure received ¼ weight in the final overall ranking process.

Lower

50 Top Cardiovascular Hospitals 19

MEASURE: Core Measures Mean Percent WHY WE INCLUDE THIS ELEMENT

CALCULATION

COMMENTS

To be truly balanced, a scorecard must include various measures of quality. Core measures, developed by The Joint Commission and CMS and endorsed by the National Quality Forum, are a widely accepted method for measuring patient care quality that includes specific guidelines for AMI and HF care.

Core measures values are from the CMS Hospital Compare Web site. We included six of the seven reported heart attack measures and all of the reported heart failure measures, for a total of 10. We excluded the heart attack core measure “Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes of Arrival” because it was not reported by most in-study hospitals. For a list of the measures used, see the Appendix.

If the hospital did not report a specific core measure, or if the core measure was based on too few patients to be sufficiently precise, we substituted the median percent for the comparison group.

For each hospital, we calculate the mean of the reported core measures percent values for all available core measures by patient group (AMI, HF). We consider reported core measures percents with patient counts that are less than or equal to 25, or that have relative standard error values greater than or equal to 0.30 to be statistically unreliable. In these cases, we substitute the class median percent value for the affected core measure.

FAVORABLE VALUES ARE Higher

Core measures values are from the CMS Hospital Compare Web site, data set published the second quarter of 2010 (with data from the fourth quarter of 2008 through the third quarter of 2009).23 Core measures received a weight of 1 in the final overall ranking process (½ for the heart attack core measure mean percent and ½ for the heart failure core measure mean percent).

MEASURE: Percentage of CABG Patients with Internal Mammary Artery Use WHY WE INCLUDE THIS ELEMENT

CALCULATION

COMMENTS

The clinical advantages of using an internal mammary graft are many. Studies over the last two decades have confirmed the benefits of internal mammary CABGs over saphenous (leg) vein grafts, with a higher patency rate being the most significant clinical benefit.18–22 On a patient-specific basis, certain factors may promote or prohibit the use of an internal mammary graft. However, it is reasonable to use the overall rate at which these grafts are performed as a measure of hospital quality.

Number of CABG surgeries using internal mammary arteries, divided by the total number of CABG surgeries. Patients with prior CABG surgeries are excluded from the calculation.

We used two years of MedPAR data (2008 and 2009) to reduce the influence of chance fluctuation.

20 Thomson Reuters

This measure received a weight of 1 in the final overall ranking process.

FAVORABLE VALUES ARE Higher

MEASURE: 30-Day Mortality Rates for AMI and HF Patients FAVORABLE VALUES ARE

WHY WE INCLUDE THIS ELEMENT

CALCULATION

COMMENTS

30-day mortality rates are a new, accepted measure of the effectiveness of overall hospital care. They allow us to look beyond immediate patient outcomes and understand how the care the hospital provided to inpatients with these particular conditions may have contributed to their longer-term survival. Because these measures are part of CMS’ value-based purchasing program, they are now being watched closely in the industry. In addition, tracking these measures may help hospitals identify patients at risk for post-discharge problems and target improvements in discharge planning and in aftercare processes. Hospitals that score well may be better prepared for pay-for performance.

CMS calculates a 30-day mortality rate for each patient condition using three years of MedPAR data combined. CMS does not calculate rates for hospitals where the number of cases is too small (less than 25). We build a database of this information for the hospitals in our study then rank the hospitals independently on each of the two conditions (AMI and HF), by hospital comparison group.

Data are from the CMS Hospital Compare data set for the second quarter of 2010. This contains data from July 1, 2006 through June 30, 2009. For more information about this data, see the Appendix.

Lower

Each patient condition receives ¼ weight, for a total 30-Day Mortality Rate weight of ½ in overall hospital ranking.

MEASURE: 30-Day Readmission Rates for AMI and HF Patients FAVORABLE VALUES ARE

WHY WE INCLUDE THIS ELEMENT

CALCULATION

COMMENTS

30-day readmission rates are a new, accepted measure of the effectiveness of overall hospital care. They allow us to understand how the care the hospital provided to inpatients with these particular conditions may have contributed to issues with their post-discharge medical stability and recovery. Because these measures are part of CMS’ value-based purchasing program, they are now being watched closely in the industry. In addition, tracking these measures may help hospitals identify patients at risk for post-discharge problems if discharged too soon, as well as target improvements in discharge planning and in aftercare processes. Hospitals that score well may be better prepared for pay-forperformance.

CMS calculates a 30-day readmission rate for each patient condition using three years of MedPAR data combined. CMS does not calculate rates for hospitals where the number of cases is too small (less than 25). We build a database of this information for the hospitals in our study then rank the hospitals independently on each of the two conditions (AMI and HF), by hospital comparison group.

Data are from the CMS Hospital Compare dataset for the second quarter of 2010. This contains data from July 1, 2006 through June 30, 2009. For more information about this data, see the Appendix.

Lower

Each patient condition receives 1/4 weight, for a total 30-Day Readmission Rate weight of 1/2 in overall hospital ranking.

50 Top Cardiovascular Hospitals 21

MEASURE: Severity-Adjusted Average Length of Stay (ALOS) WHY WE INCLUDE THIS ELEMENT

CALCULATION

COMMENTS

A lower severity-adjusted average length of stay (average number of days spent by a patient in a hospital) generally indicates a more efficient consumption of hospital resources and, possibly, reduced risk to patients.

We calculate a length of stay (LOS) index value for each patient group (AMI, HF, CABG, PCI) based on the sum of the patient-level lengths of stay divided by the sum of the normalized expected lengths of stay. Expected length of stay adjusts for differences in severity of illness using a linear regression model. We normalize the expected values based on the observed and expected LOS for each patient group (AMI, HF, CABG, and PCI). See the Appendix for more information.

Data for this measure are from 2009 MedPAR only.

FAVORABLE VALUES ARE Lower

We adjust ALOS to factor out differences attributable to the varying severity of illness of patients at each hospital POA-enabled risk models were used. For more information on this model, see the Appendix. Length of stay performance for each patient group (AMI, HF, PCI, and CABG) received a weight of ¼ in the final overall ranking process. NOTE: Each patient group LOS index is converted into an average length of stay in days by multiplying it by the grand mean of the in-study patient population, without respect to class. We then calculate the unweighted average of these severityadjusted ALOS by patient group for reporting.

MEASURE: Severity- and Wage-Adjusted Cost per Case WHY WE INCLUDE THIS ELEMENT

CALCULATION

COMMENTS

This measure helps to determine how cost effectively a hospital is caring for its patients.

We calculate a cost per case index value for each patient group (AMI, HF, CABG, PCI) based on the sum of the patient-level estimated cost divided by the sum of the normalized expected cost. Cost data is wage-adjusted. We calculate estimated cost by applying the hospital cost-to-charge ratio from the 2009 (or most recent) cost report to the patient-level charges in MedPAR.

Cost-to-charge ratios are from the hospital’s 2009 Medicare Cost Report (or 2008, if not available). In this study, we used the total cost-to-charge ratio reported by the hospital. For more information on our methodology, see the Appendix.

Expected cost adjusts for differences in severity of illness using a linear regression model. We normalize the expected values based on the observed and expected cost per case for each patient group (AMI, HF, CABG, and PCI). See the Appendix for more information.

Costs are severity adjusted to factor out differences attributable to the varying severity of illness of patients at each hospital, and are wage-adjusted to allow for regional wage variations. We use the 2009 CMS wage index for the profiled hospital. POA-enabled risk models were used.

Charge data for this measure are from 2009 MedPAR only.

Each cost per case measure (AMI, HF, PCI, CABG) received a weight of ¼ in the final overall ranking process. NOTE: Each patient group cost per case index is converted into an average cost per case expressed in dollars by multiplying it by the grand mean of the in-study patient population, without respect to class. We then calculate the unweighted average of these severity-adjusted cost per case values by patient group for reporting. For more information on our cost per case methodologies, see the Appendix. 22 Thomson Reuters

FAVORABLE VALUES ARE Lower

DETERMINING THE 50 TOP CARDIOVASCULAR HOSPITALS

Ranking Within each of the three hospital comparison groups, we ranked hospitals based on their performance on each of the measures independently, relative to other hospitals in their group. Each performance

measure is assigned a weight for use in overall ranking. The weights for each measure are indicated in the table below. Each hospitalâ&#x20AC;&#x2122;s measure ranks were summed to arrive at a total score for the hospital. The hospitals were then ranked based on their total scores, and the hospitals with the best overall rankings in each comparison group were selected as the benchmarks.

RANKED PERFORMANCE METRIC

Risk-Adjusted Mortality

Risk-Adjusted Complications

WEIGHT for AMI Patients

1/4

for HF Patients

1/4

for CABG Patients

1/4

for PCI Patients

1/4

for AMI Patients

1/4

for HF Patients

1/4

for CABG Patients

1/4

for PCI Patients

1/4

Heart Attack Core Measures Mean Percent

1/2

Heart Failure Core Measures Mean Percent

1/2

Percentage of CABG Patients With Internal Mammary Artery Use

30-Day Mortality Rates

30-Day Readmission Rates

Severity-Adjusted Average Length of Stay Index

Wage- and Severity-Adjusted Average Cost per Case Index

for AMI Patients

1/4

for HF Patients

1/4

for AMI Patients

1/4

for HF Patients

1/4

for AMI Patients

1/4

for HF Patients

1/4

for CABG Patients

1/4

for PCI Patients

1/4

for AMI Patients

1/4

for HF Patients

1/4

for CABG Patients

1/4

for PCI Patients

1/4

Note: Mortality and complications are ranked on normalized z-scores, which are converted to indexes for reporting. See Methodology detail for each measure.

50 Top Cardiovascular Hospitals 23

Screening for Outliers To reduce the impact of unsustainable performance anomalies and reporting anomalies or errors, hospitals with one or more mortality or complications index scores that were high statistical outliers (95 percent confidence) were not eligible to be winners. In addition, hospitals

COMPARISON GROUP

24 Thomson Reuters

with costs per case for any patient group that were high or low statistical outliers (using interquartile range-trimming methodology) were not eligible to be winners. The number of hospitals selected to receive the Thomson Reuters 50 Top Cardiovascular Hospitals awarded in each hospital comparison group were as follows:

TOTAL

Teaching Hospitals With Cardiovascular Residency Program

Teaching Hospitals Without Cardiovascular Residency Program

Community Hospitals

Total

WINNERS THROUGH THE YEARS HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

4th

5th

6th

7th

8th

9th 10th 11th 12th

Morton Plant Hospital

Clearwater

●

Munroe Regional Medical Center

Ocala

●

Providence Hospital and Medical Center

Southfield

●

St. Peter's Hospital

Albany

●

MeritCare Medical Center

Fargo

●

Scott and White Memorial Hospital

Temple

●

Mercy Medical Center–North Iowa

Mason City

●

Spectrum Health Hospital Group

Grand Rapids

●

Rochester General Hospital

Rochester

●

St. Joseph Medical Center

Towson

●

Beth Israel Deaconess Medical Center

Boston

●

Lahey Clinic Medical Center

Burlington

●

Oakwood Hospital and Medical Center–Dearborn

Dearborn

●

St. Joseph Mercy Oakland

Pontiac

Abbott Northwestern Hospital

Minneapolis

●

St. Cloud Hospital

St. Cloud

●

St. Mary's Medical Center

Duluth

●

The Christ Hospital

Cincinnati

●

Parkwest Medical Center

Knoxville

●

St. Mark's Hospital

Salt Lake City

●

Providence Regional Medical Center Everett

Everett

Munson Medical Center

Traverse City

Mercy Hospital

Coon Rapids

Park Nicolett Methodist Hospital

St. Louis Park

Hackensack University Medical Center

Hackensack

Mission Hospitals

Asheville

Cleveland Clinic Foundation

Cleveland

●

Riverside Methodist Hospital

Columbus

●

Hamot Medical Center

Erie

●

Robert Packer Hospital

Sayre

Saint Thomas Hospital

Nashville

●

University of Virginia Medical Center

Charlottesville

●

Aspirus Wausau Hospital

Wausau

Saint Joseph's Hospital

Marshfield

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ● ●

●

* List is ordered by years won, then state, then hospital name.

50 Top Cardiovascular Hospitals 25

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

4th

5th

6th

7th

●

Arizona Heart Hospital

Phoenix

Saint Joseph's Hospital of Atlanta

Atlanta

Saint Alphonsus Regional Medical Center

Boise

MetroSouth Medical Center

Blue Island

●

Massachusetts General Hospital

Boston

●

St. John Hospital & Medical Center

Detroit

●

William Beaumont Hospital–Royal Oak

Royal Oak

●

Billings Clinic

Billings

Dartmouth-Hitchcock Medical Center

Lebanon

Mount Carmel

Columbus

Geisinger Medical Center

Danville

Penn Presbyterian Medical Center

Philadelphia

The Miriam Hospital

Providence

●

Baylor University Medical Center

Dallas

●

LDS Hospital

Salt Lake City

●

Centra Health

Lynchburg

Gundersen Lutheran Health System

La Crosse

University of Wisconsin Hospital and Clinics

Madison

Mayo Clinic Hospital

Phoenix

Sun Health Boswell Hospital

Sun City

Yale-New Haven Hospital

New Haven

Charlotte Regional Medical Center

Punta Gorda

●

Lee Memorial Health System

Fort Myers

●

Ocala Regional Medical Center

Ocala

●

Regional Medical Center Bayonet Point

Hudson

●

Sarasota Memorial Hospital

Sarasota

●

Venice Regional Medical Center

Venice

St. Luke's Boise Medical Center

Boise

●

Loyola University Medical Center

Maywood

●

Northwest Community Hospital

Arlington Heights

St. Vincent Indianapolis Hospital

Indianapolis

●

Maine Medical Center

Portland

●

Union Memorial Hospital

Baltimore

Marquette General Hospital

Marquette

St. Joseph Mercy Hospital

Ann Arbor

St. Luke's Hospital

Chesterfield

St. Patrick Hospital and Health Sciences Center

Missoula

St. Vincent Healthcare

Billings

* List is ordered by years won, then state, then hospital name.

26 Thomson Reuters

● ●

●

● ●

●

● ●

●

9th 10th 11th 12th ●

● ●

●

8th

●

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

BryanLGH Medical Center

Lincoln

●

Good Samaritan Hospital

Dayton

●

Southwest General Health Center

Middleburg Heights

University Hospital

Cincinnati

Rogue Valley Medical Center

Medford

UPMC Presbyterian

Pittsburgh

●

York Hospital

York

●

Avera Heart Hospital of South Dakota

Sioux Falls

Baptist Hospital of East Tennessee

Knoxville

Heart Hospital of Austin

Austin

Sentara Norfolk General Hospital

Norfolk

●

Deaconess Medical Center

Spokane

●

Aurora St. Luke's Medical Center

Milwaukee

●

Thomas Hospital

Fairhope

St. Joseph's Hospital and Medical Center

Phoenix

Loma Linda University Medical Center

Loma Linda

Memorial Health System

Colorado Springs

Hospital of St. Raphael

New Haven

Cleveland Clinic Florida

Weston

Holy Cross Hospital

Fort Lauderdale

JFK Medical Center

Atlantis

Advocate Lutheran General Hospital

Park Ridge

The Indiana Heart Hospital

Indianapolis

Mercy Medical Center–Des Moines

Des Moines

Baystate Medical Center

Springfield

Borgess Medical Center

Kalamazoo

Henry Ford Hospital

Detroit

Fairview Southdale Hospital

Edina

North Shore University Hospital

Manhasset

Altru Hospital

Grand Forks

Bethesda North Hospital

Cincinnati

Mercy Medical Center

Canton

Parma Community General Hospital

Parma

University Hospitals Case Medical Center

Cleveland

Lankenau Hospital

Wynnewood

Memorial Medical Center

Johnstown

Mercy Hospital Scranton

Scranton

St. Luke's Hospital and Health Network

Bethlehem

●

2nd 3rd ●

●

● ●

●

5th

●

4th

●

6th

7th

8th

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

9th 10th 11th 12th

●

* List is ordered by years won, then state, then hospital name.

50 Top Cardiovascular Hospitals 27

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

4th

5th

The Western Pennsylvania Hospital

Pittsburgh

●

Memorial Health Care System

Chattanooga

●

Memorial Hermann Hospital System

Houston

CJW Medical Center

Richmond

●

Bellin Hospital

Green Bay

●

East Alabama Medical Center

Opelika

●

Banner Heart Hospital

Mesa

University Medical Center

Tucson

Scripps Green Hospital

La Jolla

Bridgeport Hospital

Bridgeport

Saint Francis Hospital and Medical Center

Hartford

Delray Medical Center

Delray Beach

Halifax Health Medical Center

Daytona Beach

Holmes Regional Medical Center

Melbourne

●

Lakeland Regional Medical Center

Lakeland

●

Orlando Regional Medical Center

Orlando

●

Memorial Health University Medical Center

Savannah

Edward Hospital

Naperville

St. John's Hospital

Springfield

St. Vincent Heart Center of Indiana

Indianapolis

St. Luke's Hospital

Cedar Rapids

Jewish Hospital

Louisville

King's Daughters Medical Center

Ashland

Saint Joseph–London

London

Lafayette General Medical Center

Lafayette

Brigham and Women's Hospital

Boston

UMass Memorial Medical Center

Worcester

Henry Ford Macomb Hospitals

Clinton Township

Mayo Clinic – Saint Marys Hospital

Rochester

North Memorial Health Care

Robbinsdale

St. Joseph's Hospital

St. Paul

United Hospital

St. Paul

Nebraska Heart Institute Heart Hospital

Lincoln

Morristown Memorial Hospital

Morristown

Albany Medical Center

Albany

St. Alexius Medical Center

Bismarck

Akron General Medical Center

Akron

●

EMH Regional Medical Center

Elyria

●

* List is ordered by years won, then state, then hospital name.

28 Thomson Reuters

6th

7th

8th

●

● ●

●

● ●

9th 10th 11th 12th ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

Good Samaritan Hospital

Cincinnati

●

St. Elizabeth Health Center

Youngstown

●

Summa Health System

Akron

The Toledo Hospital

Toledo

St. John Medical Center

Tulsa

Legacy Good Samaritan Hospital and Medical Center

Portland

Providence St. Vincent Medical Center

Portland

●

Lehigh Valley Hospital

Allentown

●

PinnacleHealth

Harrisburg

●

UPMC Presbyterian Shadyside

Pittsburgh

●

Rhode Island Hospital

Providence

Centennial Medical Center

Nashville

●

Wellmont Holston Valley Medical Center

Kingsport

Memorial Hermann–Texas Medical Center

Houston

Providence Health Center

Waco

Dixie Regional Medical Center

St. George

Inova Fairfax Hospital

Falls Church

Riverside Regional Medical Center

Newport News

Overlake Hospital Medical Center

Bellevue

Providence St. Peter Hospital

Olympia

●

Sacred Heart Medical Center

Spokane

●

DCH Regional Medical Center

Tuscaloosa

UAB Hospital

Birmingham

Tucson Heart Hospital

Tucson

Tucson Medical Center

Tucson

Bakersfield Memorial Hospital

Bakersfield

●

El Camino Hospital

Mountain View

●

French Hospital Medical Center

San Luis Obispo

Glendale Memorial Hospital & Health Center

Glendale

Mercy General Hospital

Sacramento

●

Saint Agnes Medical Center

Fresno

●

Torrance Memorial Medical Center

Torrance

●

Penrose-St. Francis Health Services

Colorado Springs

Hartford Hospital

Hartford

●

St. Vincent's Medical Center

Bridgeport

●

Washington Hospital Center

Washington

●

Florida Hospital Ormond Memorial

Ormond Beach

●

Gulf Coast Medical Center

Fort Myers

●

4th

5th

6th

7th

8th

9th 10th 11th 12th ● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ● ●

●

● ●

●

● ●

●

● ● ●

●

● ● ●

●

● ● ●

* List is ordered by years won, then state, then hospital name.

50 Top Cardiovascular Hospitals 29

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

4th

5th

●

6th

7th

8th

9th 10th 11th 12th

Mount Sinai Medical Center & Miami Heart Institute

Miami Beach

Shands at the University of Florida

Gainesville

Shands Jacksonville Medical Center

Jacksonville

St. Joseph's Hospital

Tampa

St. Vincent's Medical Center

Jacksonville

●

Athens Regional Medical Center

Athens

●

Medical Center of Central Georgia

Macon

●

Advocate Christ Medical Center

Oak Lawn

●

Advocate Good Samaritan Hospital

Downers Grove

Carle Foundation Hospital

Urbana

Decatur Memorial Hospital

Decatur

Memorial Hospital of Carbondale

Carbondale

Methodist Medical Center of Illinois

Peoria

NorthShore University HealthSystem

Evanston

Provena Covenant Medical Center

Urbana

●

Rush University Medical Center

Chicago

●

St. James Hospital and Health Centers

Olympia Fields

Memorial Hospital of South Bend

South Bend

●

Allen Hospital

Waterloo

●

Iowa Methodist Medical Center

Des Moines

Trinity Regional Medical Center

Fort Dodge

Wesley Medical Center

Wichita

Baptist Hospital East

Louisville

Central Baptist Hospital

Lexington

St. Elizabeth Healthcare

Edgewood

CHRISTUS St. Patrick Hospital

Lake Charles

East Jefferson General Hospital

Metairie

Ochsner Medical Center

New Orleans

Our Lady of Lourdes Regional Medical Center

Lafayette

Our Lady of the Lake Regional Medical Center

Baton Rouge

Willis-Knighton Medical Center

Shreveport

Sinai Hospital of Baltimore

Baltimore

University of Maryland Medical Center

Baltimore

Caritas St. Elizabeth's Medical Center

Boston

Covenant Medical Center Harrison

Saginaw

Mercy Health Partners

Muskegon

Mount Clemens Regional Medical Center

Mount Clemens

Sparrow Health System

Lansing

* List is ordered by years won, then state, then hospital name.

30 Thomson Reuters

● ●

●

● ●

● ● ● ● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ● ●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

● ●

●

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

St. John Macomb–Oakland Hospital

Warren

University of Michigan Hospitals & Health Centers

Ann Arbor

William Beaumont Hospital – Troy

Troy

Regions Hospital

St. Paul

Boone Hospital Center

Columbia

Heartland Regional Medical Center

Saint Joseph

St. John's Mercy Medical Center

St. Louis

St. John's Regional Medical Center

Joplin

St. Luke's Hospital of Kansas City

Kansas City

Catholic Medical Center

Manchester

Robert Wood Johnson University Hospital

New Brunswick

Ellis Hospital

Schenectady

Lenox Hill Hospital

New York

●

St. Francis Hospital

Roslyn

●

United Health Services Hospitals

Binghamton

Vassar Brothers Medical Center

Poughkeepsie

FirstHealth Moore Regional Hospital

Pinehurst

Pitt County Memorial Hospital

Greenville

Medcenter One

Bismarck

Aultman Hospital

Canton

●

Fairview Hospital

Cleveland

●

Firelands Regional Medical Center

Sandusky

Grant Medical Center

Columbus

Kettering Medical Center

Kettering

Lake Hospital System

Painesville

Mercy Hospital Fairfield

Fairfield

St. John Medical Center

Westlake

The Ohio State University Medical Center

Columbus

Sacred Heart Medical Center

Eugene

●

Allegheny General Hospital

Pittsburgh

●

Butler Memorial Hospital

Butler

Penn State Milton S. Hershey Medical Center

Hershey

Medical University of South Carolina

Charleston

Sanford USD Medical Center

Sioux Falls

Jackson-Madison County General Hospital

Jackson

Vanderbilt University Medical Center

Nashville

Harlingen Medical Center

Harlingen

Plaza Medical Center of Fort Worth

Fort Worth

2nd 3rd

4th

5th

6th

7th

8th

9th 10th 11th 12th ●

●

● ● ●

●

● ●

●

● ●

●

● ●

● ● ● ●

●

● ●

● ● ●

●

● ● ●

●

● ●

●

● ● ●

●

● ●

●

* List is ordered by years won, then state, then hospital name.

50 Top Cardiovascular Hospitals 31

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

St. David's South Austin Hospital

Austin

St. Mary's Hospital

Richmond

Winchester Medical Center

Winchester

St. Mary's Medical Center

Huntington

Aurora BayCare Medical Center

Green Bay

Baptist Medical Center South

Montgomery

Mobile Infirmary Medical Center

Mobile

●

Physicians Medical Center Carraway

Birmingham

●

Southeast Alabama Medical Center

Dothan

St. Vincent's Hospital

Birmingham

●

Trinity Medical Center

Birmingham

●

Arrowhead Hospital

Glendale

Banner Good Samaritan Medical Center

Phoenix

Northwest Medical Center

Tucson

Phoenix Memorial Hospital

Phoenix

Phoenix Regional Medical Center

Phoenix

●

St. Edward Mercy Medical Center

Fort Smith

●

California Pacific Medical Center

San Francisco

Eisenhower Medical Center

Rancho Mirage

Hoag Memorial Hospital Presbyterian

Newport Beach

John Muir Medical Center, Concord Campus

Concord

Kaiser Permanente Los Angeles Medical Center

Los Angeles

Kaiser Permanente San Francisco Medical Center

San Francisco

Kaweah Delta Hospital

Visalia

●

Long Beach Memorial Medical Center

Long Beach

●

Mercy Medical Center Redding

Redding

Methodist Hospital of Southern California

Arcadia

Mills-Peninsula Health Services

Burlingame

Pomona Valley Hospital Medical Center

Pomona

Providence Little Company of Mary Medical Center

Torrance

Providence Saint Joseph Medical Center

Burbank

Salinas Valley Memorial Healthcare System

Salinas

San Joaquin Community Hospital

Bakersfield

Scripps Mercy Hospital

San Diego

Sequoia Hospital

Redwood City

Seton Medical Center

Daly City

* List is ordered by years won, then state, then hospital name.

32 Thomson Reuters

4th

●

5th

6th

7th

●

8th

9th 10th 11th 12th ●

●

● ●

●

● ● ● ●

● ● ●

●

● ●

●

● ● ● ●

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

Shasta Regional Medical Center

Redding

St. Helena Hospital

St. Helena

St. Joseph's Medical Center

Stockton

St. Mary's Medical Center

San Francisco

Stanford Hospital & Clinics

Stanford

Washington Hospital Healthcare System

Fremont

Exempla Saint Joseph Hospital

Denver

North Colorado Medical Center

Greeley

Presbyterian/St. Luke's Medical Center

Denver

St. Anthony Central Hospital

Denver

St. Mary's Hospital and Regional Medical Center

Grand Junction

Baptist Hospital

Pensacola

Blake Medical Center

Bradenton

Broward General Medical Center

Fort Lauderdale

Central Florida Regional Hospital

Sanford

Florida Hospital

Orlando

Florida Hospital–Ormond Memorial

Ormond Beach

Florida Medical Center

Fort Lauderdale

Largo Medical Center

Largo

Leesburg Regional Medical Center

Leesburg

Martin Memorial Medical Center

Stuart

Memorial Regional Hospital

Hollywood

Miami Heart Institute South

Miami Beach

NCH Downtown Naples Hospital

Naples

North Ridge Medical Center

Fort Lauderdale

Palm Beach Gardens Medical Center

Palm Beach Gardens

Tallahassee Memorial HealthCare

Tallahassee

●

Emory Crawford Long Hospital

Atlanta

●

Emory University Hospital

Atlanta

●

Piedmont Hospital

Atlanta

Redmond Regional Medical Center

Rome

Straub Clinic & Hospital

Honolulu

Central DuPage Hospital

Winfield

Ingalls Memorial Hospital

Harvey

Mercy Hospital & Medical Center

Chicago

Northwestern Memorial Hospital

Chicago

2nd 3rd

4th

5th

6th

7th

8th

9th 10th 11th 12th

● ● ● ● ●

●

● ● ● ●

●

● ●

●

● ● ●

●

● ● ● ● ● ●

●

● ● ● ● ● ● ●

* List is ordered by years won, then state, then hospital name.

50 Top Cardiovascular Hospitals 33

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

OSF Saint Francis Medical Center

Peoria

OSF St. Joseph Medical Center

Bloomington

Riverside Medical Center

Kankakee

Rush North Shore Medical Center

Skokie

Saint Francis Hospital

Evanston

Sherman Hospital

Elgin

Ball Memorial Hospital

Muncie

Bloomington Hospital

Bloomington

Community Hospital

Munster

Community Hospital East/North

Indianapolis

Deaconess Hospital & Health System

Evansville

Saint Margaret Mercy Healthcare Centers

Hammond

St. Elizabeth Medical Center

Lafayette

Union Hospital

Terre Haute

Genesis Medical Center East

Davenport

Mercy Medical Center – Sioux City

Sioux City

Stormont-Vail HealthCare

Topeka

The University of Kansas Hospital

Kansas City

St. Joseph Hospital

Lexington

Trover Health System

Madisonville

Western Baptist Hospital

Paducah

Heart Hospital of Lafayette

Lafayette

Louisiana Medical Center & Heart Hospital

Lacombe

Rapides Regional Medical Center

Alexandria

St. Francis Medical Center

Monroe

Peninsula Regional Medical Center

Salisbury

●

Washington Adventist Hospital

Takoma Park

●

Boston Medical Center

Boston

Mount Auburn Hospital

Cambridge

North Shore Medical Center

Salem

Tufts-New England Medical Center

Boston

Bronson Methodist Hospital

Kalamazoo

Northern Michigan Regional Hospital

Petoskey

St. Mary's of Michigan

Saginaw

Memorial Hospital

Gulfport

●

North Mississippi Medical Center

Tupelo

●

Barnes-Jewish Hospital

Saint Louis

Freeman Health System

Joplin

SSM St. Mary's Health Center

St. Louis

Desert Springs Hospital

Las Vegas

* List is ordered by years won, then state, then hospital name.

34 Thomson Reuters

4th

5th

6th

7th

8th

9th 10th 11th 12th

● ● ● ● ● ● ● ● ● ● ●

●

● ● ● ● ● ● ● ● ● ●

●

● ●

● ● ● ● ● ● ●

● ● ● ●

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

Sunrise Hospital & Medical Center

Las Vegas

Newark Beth Israel Medical Center

Newark

Passaic Beth Israel Regional Medical Center

Passaic

Lovelace Medical Center

Albuquerque

Presbyterian Hospital

Albuquerque

Erie County Medical Center

Buffalo

●

Kaleida Health

Buffalo

●

Long Island Jewish Medical Center

New Hyde Park

●

Maimonides Medical Center

Brooklyn

Millard Fillmore Gates Circle Hospital

Buffalo

●

St. Joseph's Hospital Health Center

Syracuse

●

St. Luke's-Roosevelt Hospital Center

New York

●

St. Vincent's Manhattan

New York

●

Staten Island University Hospital

Staten Island

The Mount Sinai Medical Center

New York

Carolinas Medical Center–NorthEast

Concord

Duke University Hospital

Durham

High Point Regional Health System

High Point

Presbyterian Hospital

Charlotte

Rex Healthcare

Raleigh

●

WakeMed Releigh Campus

Raleigh

●

Deaconess Hospital

Cincinnati

Forum Health Northside Medical Center

Youngstown

Grandview Medical Center

Dayton

Hillcrest Hospital

Mayfield Heights

Jewish Hospital

Cincinnati

Miami Valley Hospital

Dayton

INTEGRIS Baptist Medical Center

Oklahoma City

●

Mercy Health Center

Oklahoma City

●

Oklahoma Heart Hospital

Oklahoma City

OU Medical Center

Oklahoma City

Saint Francis Hospital

Tulsa

Good Samaritan Regional Medical Center

Corvallis

Providence Portland Medical Center

Portland

DuBois Regional Medical Center

DuBois

Excela Health Westmoreland

Greensburg

Lancaster General Hospital

Lancaster

Saint Vincent Health Center

Erie

4th

5th

6th

7th

8th

9th 10th 11th 12th

● ●

●

● ●

●

● ● ● ● ● ●

●

● ●

● ● ●

●

● ● ● ● ●

* List is ordered by years won, then state, then hospital name.

50 Top Cardiovascular Hospitals 35

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

4th

5th

6th

St. Francis Medical Center

Pittsburgh

Thomas Jefferson University Hospital

Philadelphia

UPMC Mercy

Pittsburgh

UPMC Passavant

Pittsburgh

Williamsport Regional Medical Center

Williamsport

Grand Strand Regional Medical Center

Myrtle Beach

Spartanburg Regional Healthcare System

Spartanburg

Avera McKennan Hospital & University Health Center

Sioux Falls

Rapid City Regional Hospital

Rapid City

Erlanger Health System

Chattanooga

Fort Sanders Regional Medical Center

Knoxville

Johnson City Medical Center

Johnson City

St. Mary's Medical Center

Knoxville

The University of Tennessee Medical Center

Knoxville

CHRISTUS Santa Rosa Health Care

San Antonio

Christus Spohn Hospital Corpus Christi – Shoreline

Corpus Christi

Corpus Christi Medical Center

Corpus Christi

Covenant Health System

Lubbock

●

Denton Regional Medical Center

Denton

●

Doctors Hospital at Renaissance

Edinburg

Good Shepherd Medical Center

Longview

Medical Center Hospital

Odessa

Memorial Hermann Memorial City Medical Center

Houston

Seton Medical Center Austin

Austin

●

The Medical Center of Southeast Texas

Port Arthur

●

The Methodist Hospital

Houston

●

Trinity Mother Frances Hospital

Tyler

●

Valley Baptist Medical Center

Harlingen

Woodland Heights Medical Center

Lufkin

McKay-Dee Hospital Center

Ogden

Utah Valley Regional Medical Center

Provo

Fletcher Allen Health Care

Burlington

Carilion Clinic

Roanoke

Henrico Doctors' Hospital

Richmond

Memorial Regional Medical Center

Mechanicsville

VCU Medical Center

Richmond

Central Washington Hospital

Wenatchee

Southwest Washington Medical Center

Vancouver

* List is ordered by years won, then state, then hospital name.

36 Thomson Reuters

7th

8th

9th 10th 11th 12th

● ● ● ● ● ●

●

● ● ● ● ●

●

● ● ●

●

● ● ● ● ● ● ● ● ● ● ●

HOSPITAL*

CITY

STATE

TOTAL YEAR(S) WON

STUDY EDITIONS 1st

2nd 3rd

St. Joseph Hospital

Bellingham

●

Virginia Mason Medical Center

Seattle

●

Yakima Regional Medical and Cardiac Center

Yakima

Appleton Medical Center

Appleton

Froedtert & the Medical College of Wisconsin

Milwaukee

Meriter Hospital

Madison

St. Elizabeth Hospital

Appleton

Waukesha Memorial Hospital

Waukesha

4th

5th

6th

7th

8th

9th 10th 11th 12th

●

● ● ●

* List is ordered by years won, then state, then hospital name.

50 Top Cardiovascular Hospitals 37

APPENDIX: METHODOLOGY DETAILS METHODS FOR IDENTIFYING COMPLICATIONS OF CARE

Risk-Adjusted Mortality Index Models Without adjusting for differences, comparing outcomes among hospitals is like comparing the proverbial apples to oranges: hard, if not impossible, to do. To make valid normative comparisons of hospital outcomes, we must adjust raw data to accommodate for differences that result from the variety and severity of admitted cases. We must also account for individual facility characteristics that affect quality of care measures, such as the hospitalâ&#x20AC;&#x2122;s geographic location, size, teaching status, and community setting (urban versus rural). Thomson Reuters is able to make valid normative comparisons of mortality and complications rates by using patient-level data to control effectively for case mix and severity differences. We do this by evaluating ICD-9-CM diagnosis and procedure codes to adjust for severity within clinical case mix groupings. Conceptually, we group patients with similar characteristics (i.e., age, sex, principal diagnosis, procedures performed, admission type, and comorbid conditions) to produce expected, or normative, comparisons. In the same way, we group facilities with similar characteristics. Through extensive testing, we have found that this methodology produces valid normative comparisons using readily available administrative data, eliminating the need for additional data collection. Thomson Reuters constructs a normative database of case-level data from its Projected Inpatient Data Base (PIDB), a national all-payer database containing more than 21 million all-payer discharges annually. These data are obtained from approximately 2,500 hospitals, representing 50 percent of all discharges from short-term, general, nonfederal hospitals in the United States. The data include age, sex, and length of stay;

clinical groupings: Medicare Severity Diagnosis Related Groups (MS-DRGs), ICD-9-CM principal and secondary diagnoses, ICD-9-CM principal and secondary procedures; hospital identification; admission source and type; and discharge status. Hospital characteristics are obtained by linking each hospitalâ&#x20AC;&#x2122;s identification number with American Hospital Association and Medicare Cost Report data. From the model, we exclude long-term care facilities; psychiatric, rehabilitation, or other specialty facilities; and federally owned or controlled facilities. Excluded patient groups are newborns, cases transferred to other short-term hospitals, and cases with stays shorter than one day. A standard logistic regression model is used to estimate the risk of mortality or complications for each patient. This is done by weighting the patient records of the client hospital by the logistic regression coefficients associated with the corresponding terms in the model and the intercept term. This produces the expected probability of an outcome for each eligible patient (numerator) based on the experience of the norm for patients with similar characteristics (age, clinical grouping, severity of illness, and so forth) at similar institutions (hospital bed size, census division, teaching status, urban or rural community setting).24â&#x20AC;&#x201C;28 This methodology also ensures that facilities are compared to other facilities with similar characteristics. Staff physicians at Thomson Reuters have suggested important clinical patient characteristics that were also incorporated into the proprietary models. After assigning the predicted probability of the outcome for each patient, the patient-level data can then be aggregated across a variety of groupings including hospital, service, or the MS-DRG classification systems, which were originally developed at Yale University in the 1980s.

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Expected Complications Rate Index Models Risk-adjusted complications refer to outcomes that may be of concern when they occur at a greater than expected rate among groups of patients, possibly reflecting systemic quality of care issues.

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The Thomson Reuters complications model uses clinical qualifiers to identify complications that have probably occurred in the inpatient setting. The complications used in the model are:

COMPLICATION

PATIENT GROUP

Post-operative complications relating to urinary tract

Surgical only

Post-operative complications relating to respiratory system except pneumonia

Surgical only

GI complications following procedure

Surgical only

Infection following injection/infusion

All patients

Decubitus ulcer

All patients

Post-operative septicemia, abscess, and wound infection

Surgical, including cardiac

Aspiration pneumonia

Surgical only

Tracheostomy complications

All patients

Complications of cardiac devices

Surgical, including cardiac

Complications of vascular and hemodialysis devices

Surgical only

Nervous system complications from devices/complications of nervous system devices

Surgical only

Complications of genitourinary devices

Surgical only

Complications of orthopedic devices

Surgical only

Complications of other and unspecified devices, implants, and grafts

Surgical only

Other surgical complications

Surgical only

Miscellaneous complications

All patients

Cardio-respiratory arrest, shock, or failure

Surgical only

Post-operative complications relating to nervous system

Surgical only

Post-operative acute myocardial infarction

Surgical only

Post-operative cardiac abnormalities except AMI

Surgical only

Procedure-related perforation or laceration

All patients

Post-operative physiologic and metabolic derangements

Surgical, including cardiac

Post-operative coma or stupor

Surgical, including cardiac

Post-operative pneumonia

Surgical, including cardiac

Pulmonary embolism

All patients

Venous thrombosis

All patients

Hemorrhage, hematoma or seroma complicating a procedure

All patients

Post-procedure complications of other body systems

All patients

Complications of transplanted organ (excludes skin and cornea)

Surgical only

Disruption of operative wound

Surgical only

A normative database of case-level data including age, sex, length of stay, clinical grouping (MSDRGs), comorbid conditions, and hospital identification is constructed using our national all-payer database. Hospital characteristics are obtained by linking each hospital's identification number with American Hospital Association and Medicare Cost Report data. The method includes patients from approximately 2,500 short-term, general, nonfederal hospitals that are generally representative of short-term, general, nonfederal hospitals in the United States. Excluded groups are neonates, cases transferred to other short-term hospitals, and cases with stays shorter than one day. Also, clinical groupings such as psychiatry/mental illness, substance abuse, rehabilitation, obstetrics, and pediatrics (under 17 years of age), requiring special consideration with regard to complications outcomes, and so are excluded from the general risk-adjusted complications measure.

The index is simply the number of observed events divided by the number of expected events and can be calculated for outcomes which involve counts of occurrences (e.g., deaths or complications). Interpretation of the index relates the experience of the comparison population relative to a specified event to the expected experience based on the normative population.

Complication rates are calculated from normative data for two patient risk groups: medical and surgical. A standard regression model is used to estimate the risk of experiencing a complication for each patient. This is done by weighting the patient records of the client hospital by the regression coefficients associated with the corresponding terms in the prediction models and intercept term. This method produces the expected probability of a complication for each patient based on the experience of the norm for patients with similar characteristics at similar institutions. After assigning the predicted probability of a complication for each patient in each risk group, it is then possible to aggregate the patient-level data across a variety of groupings.29–32

10 events observed ÷ 25 events expected = 0.4: The observed number of events is 60 percent lower than the expected number of events based on the normative experience.

Index Interpretation An outcome index is a ratio of an observed number of outcomes to an expected number of outcomes in a particular population. This index is used to make normative comparisons and is standardized in that the expected number of events is based on the occurrence of the event in a normative population. The normative population used to calculate expected numbers of events is selected to be similar to the comparison population with respect to relevant characteristics including age, sex, region, and case mix.

Examples: 10 events observed ÷ 10 events expected = 1.0: The observed number of events is equal to the expected number of events based on the normative experience. 10 events observed ÷ 5 events expected = 2.0: The observed number of events is twice the expected number of events based on the normative experience.

Therefore, an index value of 1.0 indicates no difference between observed and expected outcome occurrence. An index value greater than 1.0 indicates an excess in the observed number of events relative to the expected based on the normative experience. An index value less than 1.0 indicates fewer events observed than would be expected based on the normative experience. An additional interpretation is that the difference between 1.0 and the index is the percentage difference in the number of events relative to the norm. In other words, an index of 1.05 indicates 5 percent more outcomes, and an index of 0.90 indicates 10 percent fewer outcomes than expected based on the experience of the norm. The index can be calculated across a variety of groupings (e.g., hospital, service, and DRG). Note: Present on admission (POA) data was not taken into account in the calculation of expected values for mortality or complications because we require two years of MedPAR data to increase the stability of the results. POA data only became widely available in the 2009 MedPAR data set. We will add this factor in the next study.

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CORE MEASURES

Core measures were developed by The Joint Commission and Centers for Medicare and Medicaid Services (CMS) and endorsed by the National Quality Forum, as minimum basic care standards. They are a widely accepted method for measuring patient care quality that includes specific guidelines for heart attack, heart failure, pneumonia, pregnancy and related conditions, and surgical infection prevention. Our core measures metric for this study is based on the heart attack and heart failure areas of this program, using Hospital Compare data reported by CMS. We included six of the seven reported heart attack measures and all of the reported heart failure measures. We excluded the AMI core measure “Heart Attack Patients Given Fibrinolytic Medication within 30 Minutes of Arrival” because it was not reported by most in-study hospitals.5 For each hospital, and for each patient group we calculate the mean of the reported core measures percent values for all available core measures. We consider reported core measures percents with patient counts that are less than or equal to 25, or that have relative standard error values greater than or equal to 0.30 to be statistically unreliable. In these cases, we substitute the class median percent value for the affected core measure. The included core measures are: Heart Attack Core Measures 1. Patients given angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) for left ventricular systolic (LVS) dysfunction 2. Patients given aspirin at arrival 3. Patients given aspirin at discharge 4. Patients given beta blocker at discharge 5. Patients given PCI within 90 minutes of arrival 6. Patients given smoking cessation counseling Heart Failure Core Measures 1. Patients given ACE inhibitor or ARB for left ventricular systolic dysfunction 2. Patients given evaluation of LVS function 3. Patients given smoking cessation counseling 4. Patients given discharge instructions

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LENGTH OF STAY AND COST PER CASE METHODOLOGIES

The study’s length of stay and cost per case performance measures use Thomson Reuters propriety severity-adjusted resource demand methodologies. This model now includes present on admission (POA) data that was reported in the 2009 MedPAR data set. Under the Deficit Reduction Act of 2005, as of federal fiscal year 2008, hospitals do not receive payment for cases with certain conditions, like falls, surgical site infections, and pressure ulcers, that were not present on the patient’s admission but occur during their hospitalization. As a result, CMS now requires all inpatient prospective payment system hospitals to document whether a patient has these conditions when admitted.14 Our severity-adjusted resource demand model allows us to produce risk-adjusted performance comparisons on length of stay (LOS) and hospital charges between or across virtually any subgroup of inpatients. These patient groupings can be based on MS-DRGs, hospitals, product lines, geographic regions, physicians, etc. The methodology adjusts for differences in diagnosis type and illness severity, based on ICD-9-CM coding. It also adjusts for patient age, gender, and admission status, in addition to selected hospital characteristics such as bed size, census division, teaching status, and urban or rural community setting. Its associated LOS and charge weights allow group comparisons on a national level and in a specific market area. These weights are calculated separately for LOS and charges from the PIDB. PIDB discharges are statistically weighted to represent the universe of all short-term, general, nonfederal hospitals in the United States. Compared with the refined diagnosis-related group (RDRG) grouper-based methodologies we used previously, this regression-based model incorporates more information, such as hospital characteristics, and provides more accuracy in predicting results. The POA component allows us to determine appropriate adjustments based on previous conditions versus complications. We calculate expected values from model coefficients that are normalized to the clinical group and transformed from log scale. The model further adjusts for hospital factors to ensure accurate comparisons.

We estimate costs using the total cost-to-charge ratio (reported in the hospital’s most current cost report), applied to the specific charges reported for the study’s cardiovascular patients (AMI, HF, CABG, and PCI) in the MedPAR file. To account for geographic cost of living differences, expected values are adjusted for each hospital using the CMS wage index for the federal fiscal year that matches the MedPAR file year. PERFORMANCE MEASURE NORMALIZATION

The mortality, complications, length of stay, and cost measures are normalized, based on the in-study population, by comparison group, to provide a more easily interpreted comparison among hospitals. To address the impact of bed size, teaching status, and residency program involvement and compare hospitals to other like hospitals, we assign each hospital in the study to one of three comparison groups (Teaching Hospitals With Cardiovascular Residency Programs, Teaching Hospitals Without Cardiovascular Residency Programs, and Community Hospitals). Detailed descriptions of the patient and hospital comparison groups can be found in the Methodology section of this document. For the mortality and complications measures, we base our scoring on the difference between observed and expected events, expressed in standard deviation units (z-scores) that have been normalized. We normalize the individual hospital z-scores by finding the difference between the hospital z-score and the mean z-score for their comparison group. The difference is then divided by the standard deviation of the comparison group’s z-scores to produce the normalized z-score for the hospital.

For length of stay and cost measures, we base our scoring on the severity-adjusted LOS index and the wage- and severity-adjusted cost per case index. These indices are the ratio of the observed and the normalized expected values for each hospital, where the expected values are the sum of the weights for the hospital cases included in the measure. We normalize the individual hospital expected values by multiplying them by the ratio of the observed to expected values for the comparison group. The hospital’s normalized index is then calculated by dividing the hospital’s observed value by its normalized expected value to produce the normalized index for the hospital. WHY WE HAVE NOT CALCULATED PERCENT CHANGE IN SPECIFIC INSTANCES

We do not calculate winner (benchmark) versus peer percent differences when the performance measure value is already in units of percent. In this case, we report linear difference only. Percent change is a meaningless statistic when the underlying quantity can be positive, negative, or zero. The actual change may mean something, but dividing it by a number that may be zero or of the opposite sign does not convey any meaningful information because the amount of change is not proportional to its previous value.32

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2. Peterson ED, Rose MT, Mulgund J, et al. Association between hospital process performance and outcomes among patients with acute coronary syndrome. JAMA. 2006;295:1912-1920. 3. Huffman MD, Bonow RO. Clinical practice guidelines and scientific evidence. JAMA. 2009 July 8;302(2):144-5; author reply 146-7. 4. van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345(19):1359–1367. 5. Lazar HL, McDonnell M, Chipkin SR, et al. Society of Thoracic Surgeons Blood Glucose Guideline Task Force. The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg 2009;87(2):663-669. 6. Frioud A, Comte-Perret S, Nguyen S et al. Blood glucose level on postoperative day 1 is predictive of adverse outcomes after cardiovascular surgery. Diabetes Metab. 2010 Feb;36(1):36-42. 7. Latham R, Landcaster AD, Covington JF et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol. 2001 Oct;22(10):607-12. 8. Zerr KJ, Furnary AP, Grunkemeier GL et al. Glucose control lowers the risk of wound infection in diabetics after open heart surgery. Ann Thora Surg. 1997 Feb;63(2):356-61. 9. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade. J Am Coll Cardio. 2009 Nov 24; 54(22):2102-2128. 10. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. J Am Coll Cardio. 2009 Nov 24; 54:e13-e118. 11. Chopra V, Eagle KA. Perioperative Beta-Blockers for Cardiac Risk Reduction: Time for Clarity. JAMA. 2010 Feb 10; 303(6):551-552. 12. Wallace AW, Au S, Cason BA. Association of the Pattern of Use of Perioperative Beta-Blockade and Postoperative Mortality. Anesthesiology. 2010 Oct; 113(4):794-805. 13. Shammash JB, Trost JC, Gold JM, et al. Perioperative beta-blocker withdrawal and mortality in vascular surgical patients. Am Heart J. 2001 Jan;141(1)148-53. 14. For more information on the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Conditions (Present on Admission Indicator) program, see cms.gov/HospitalAcqCond/. 15. CMS has ruled that no data points based on fewer than 11 discharges may be displayed. To comply with this rule, we excluded any values based on fewer than 11 discharges. 16. We obtain GME program involvement data annually from the Accreditation Council for Graduate Medical Education (ACGME). This year’s study is based on ACGME files from September 2009.

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17. AOA residency information was collected from the AOA Web site (opportunities.osteopathic.org) in September 2009. 18. Tatoulis, J, Buxton, BF, Fuller, JA. Patencies of 2127 arterial to coronary conduits over 15 years. Ann Thorac Surg 2004; 77:93. 19. Sabik JF, 3rd, Lytle, BW, Blackstone, EH, et al. Comparison of saphenous vein and internal thoracic artery graft patency by coronary system. Ann Thorac Surg 2005; 79:544. 20. Goldman, S, Zadina, K, Moritz, T, et al. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study. J Am Coll Cardiol 2004; 44:2149. 21. Cohn LH. Use of the Internal Mammary Artery Graft and In-Hospital Mortality and Other Adverse Outcomes Associated with Coronary Artery Bypass Surgery. Circulation. 2001; 103:483. 22. Loop F, Lytle B, et al. Influence of the Internal-Mammary-Artery Graft on 10-Year Survival and Other Cardiac Events. NEJM. 1986; 314:1-6. 23. CMS Hospital Compare can be viewed at hospitalcompare.hhs.gov/. 24. DesHarnais SI, McMahon LF Jr, Wroblewski RT. Measuring Outcomes of Hospital Care Using Multiple Risk-Adjusted Indexes. Health Serv Res. 26, no. 4 (Oct 1991): 425-445. 25. DesHarnais SI, et al. The Risk Adjusted Mortality Index: A New Measure of Hospital Performance. Medical Care. 26, no. 12 (Dec 1988): 1129-1148. 26. DesHarnais SI, et al. Risk-Adjusted Quality Outcome Measures: Indexes for Benchmarking Rates of Mortality, Complications, and Readmissions. Qual Manag Health Care. 5 (Winter 1997): 80-87. 27. DesHarnais SI, et al. Measuring Hospital Performance: the Development and Validation of Risk-Adjusted Indexes of Mortality, Readmissions, and Complications. Medical Care. 28, no. 12 (Dec 1990): 1127-1141. 28. Iezzoni LI, et al. Chronic Conditions and Risk of In-Hospital Death. Health Serv Res. 29, no. 4 (Oct 1994): 435-460. 29. Iezzoni LI, et al: Identifying Complications of Care Using Administrative Data. Med Care. 32, no.7 (Jul 1994): 700-715. 30. Iezzoni LI, et al. Using Administrative Data to Screen Hospitals for High Complication Rates. Inquiry. 31, no. 1 (Spring 1994): 40-55. 31. Iezzoni LI. Assessing Quality Using Administrative Data. Ann Intern Med. 127, no. 8 (Oct 1997): 666-674. 32. Weingart SN, et al. Use of Administrative Data to Find Substandard Care: Validation of the Complications Screening Program. Med Care. 38, no. 8 (Aug 2000): 796-806. 33. Wall Street Journal, New York, NY, Help: Digest of Earnings (online.wsj.com/public/resources/ documents/doe-help.htm).

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