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Medicare study finds teaching hospitals have higher risk of complications; findings disputed

By Jordan Rau,

Patients flock to many of America’s teaching hospitals seeking the most advanced treatments for serious and complex diseases. But once there, they are at heightened risk for preventable complications, according to Medicare’s first public evaluation of hospitals’ records on patient safety.

Medicare has begun publishing the rates of complications as a step toward using them to set payment rates for thousands of hospitals. But leaders of a number of the nation’s prestigious teaching hospitals are objecting to the approach, which has intensified a debate about the accuracy and fairness of a series of efforts by the government to judge — and ultimately pay — hospitals on the quality of their care.

Georgetown University Hospital, Washington Hospital Center, the Cleveland Clinic, Mount Sinai Hospital in New York City and Geisinger Medical Center in Danville, Pa., were among the institutions having substantially more complications than the average, according to data evaluated by the Medicare program.

A central tenet of the 2010 federal health-care law will tie Medicare reimbursement to a variety of measures, including how patients rate their stays, readmission, mortality rates and how closely hospitals adhere to basic guidelines for care. The administration thinks adding such financial incentives into Medicare, which is the nation’s largest insurer and covers 47 million seniors and disabled people, will prod hospitals to lower costs and improve treatment.

The effort is to begin in October with a few initial metrics, and Medicare is poised to add the patient-safety measures to the mix as early as fall 2013. But the reservations raised about the safety measures are echoed by a number of independent experts, including some who have been at the forefront of efforts to improve patient safety.

In January, a panel created by the National Quality Forum, a nonprofit organization that advises Medicare on quality, recommended against using the patient-safety measure for payment “due to concerns about the reliability of the data sources.” Atul Grover, head of public policy at the Association of American Medical Colleges, said, “They need to either revisit and refine it or drop it completely.”

Medicare has published the information on its Hospital Compare Web site (hospitalcompare.
hhs.gov
) for consumers to see. And some insurers may add it to the factors they consider when deciding how much to pay hospitals. “I am encouraged they are expanding the measures,” said Sam Ho, chief medical officer at UnitedHealthcare.

But officials at many of the hospitals listed as having high rates of complications say the measures are fundamentally skewed in ways that exaggerate problems at hospitals that treat many complicated cases or very sick patients.

“Not all of these metrics are ready for prime time,” George Blike, who oversees safety at Dartmouth Hitchcock Medical Center and Mary Hitchcock Memorial Hospital in Lebanon, N.H., which Medicare ranked as having a high rate of complications. “It’s unfortunately going to create a lot of confusion for the public.”

Janis Orlowski, chief medical officer at Washington Hospital Center, said hospital officials examined the cases that led Medicare to rate her hospital as having a high rate of accidental cuts and lacerations. They found most of those cuts had been intended by the surgeon, but erroneously billed to Medicare under the code for an accidental cut. Orlowski emphasized that the hospital didn’t gain financially by the error, as both codes pay the same amount.

“Even though on the [Hospital Compare] Web site today we’re worse on national rates, we can tell you 100 percent we have no problem with accidental cuts and punctures,” Orlowski said.

In an e-mailed statement, Georgetown said in 2010 it created a new center focused on improving patient safety. The Hospital Compare data cover October 2008 through June 2010. Georgetown said that based on more recent data, “We believe we are moving in a positive direction when it comes to patient safety and the areas cited on the Hospital Compare website.”

The Medicare data show high rates of serious complications for elderly patients at three out of 10 major teaching hospitals, including some of the biggest institutions in Boston, Philadelphia, Los Angeles, Cleveland and Chicago. Overall, teaching hospitals were nearly 10 times as likely as other hospitals to have high complication rates, according to a Kaiser Health News analysis of the data.

The data cover Medicare patients but the government thinks that is indicative of a hospital’s overall quality. Medicare calculates each hospital’s overall, or “composite,” rate of complications, by looking at the frequencies of punctured lungs, blood clots after surgery, accidental cuts and tears, bedsores, catheter and bloodstream infections, and broken hips from falling after surgery. Shaheen Halim, who directs Medicare’s division measuring hospital quality, said the indicators appropriately factor in the varied mix of patients a hospital sees, “leveling the playing field for comparisons.”

Donald Goldmann, a senior vice president at the Institute for Healthcare Improvement, said the Medicare billing records — the basis of the patient-safety evaluations — are not refined enough to properly distinguish between the various levels of illness and health problems among patients. “These patient safety indicators, they’re not real­ly well risk-adjusted,” Goldmann said. “We’re using crude, not very well validated administrative data to make comparisons.”

The indicators were never intended to compare hospitals, said Gina Pugliese, a patient safety expert at Premier, an alliance of 2,300 hospitals. “They were developed and intended to help hospitals flag events they could drill down and spend more time on,” she said.

In its summary rate for complications, Medicare identified 190 of 3,330 hospitals as having very high levels. Of those, 82 were major teaching hospitals, according to the KHN analysis. While 31 percent of major teaching hospitals were categorized as having high rates of complications, only 4 percent of other hospitals — those with no residents or just a handful of them — were flagged as having high rates.

Barbara Rudolph, senior science director at the Leapfrog Group, which evaluates hospitals, said the high complication rates at big teaching hospitals might be real. “It’s much more difficult in a large institution to adequately train everyone to do the right thing,” she said. “You tend to have more residents and fellows flowing through.”

That’s not what Cleveland Clinic officials say they discovered when they delved into the data. Shannon Phillips, a quality and patient safety officer at the Cleveland Clinic, said the clinic’s high rates of accidental tears and lacerations and serious blood clots were because “people are careful at documenting, almost to a fault, things that are incidental to the case.”

Not all the hospitals ranked as having high complication rates dispute Medicare’s assessment. “We’re perfectly fine with the way [Medicare] does public reporting data,” said John Bulger, chief quality officer at Geisinger. “At Geisinger, we would never shy away from the number and say, ‘We don’t need to get better than this.’ ”

But Gregg Meyer, head of patient safety at Massachusetts General Hospital in Boston, predicted that many hospitals will react to the publication of the patient safety data by instructing those who fill out the billing records to change what they include, or by lavishing staff attention on the areas flagged by Medicare even if they aren’t a real problem. “You’d be throwing resources that would really be better spent taking care of patients,” he said.

— Kaiser Health News

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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