The Doctor Weighs In

I have a file full of warranties on things I have purchased. They give me peace of mind. Sometimes, they even save me money. Now, a hospital system – The Geisinger Health System in central Pennsylvania -- is providing warranties for heart surgery. You don’t have to pay extra to get your defects related to surgery repaired if they occur within 90 days of the operation. Brilliant idea!

Only in health care, with its many perverse financial incentives, do you have a situation where a provider has the opportunity to make more money by providing shoddy care than providing good care. What do I mean by that? Let me give you an example. If you are admitted to the hospital and get an infection related to inadequate infection control. Treatment of that hospital-acquired infection prolongs your hospitalization and you use more expensive services, such as intravenous antibiotics. In a fee-for-service world, that means more revenue for the hospital. Not only does this generate extra costs, it also fails to provide an incentive to do things right the first time (and every time).

Starting in 2006, Geisinger Health System began exploring how to make elective heart bypass surgery flawless. And, to put there money where their mouth is, so to speak, they combined their quality improvement efforts with a 90 day warranty.

Doctors at Geisinger reviewed all of the steps in these elective surgeries and identified 40 as essential to achieve good outcomes. Then they created procedures to ensure these 40 steps are always followed, not matter who the surgeon or where the operation is performed. Hmmm….sounds like the checklists pilots use to make sure everything is in order before the plane takes off.

Here is the checklist:

1. Preadmission documentation:

a. Document the American College of Cardiology/American Heart Association indication for surgery

b. Screening for and consultation regarding IMI (inferior myocardial infarction)/RV

(right ventricular) involvement

c. Record treatment options and patient preferences

d. Determine and document the need for anticoagulation with warfarin – Anterior MI (myocardial infarction) or WMA (wall motion abnormality)

e. Record whether the patient is a current user of anticoagulation medications (clopidogrel or warfarin)?

f. Screen the patient for risk of stroke

g. Obtain a carotid doppler ultrasound exam (test for stroke) if the test is indicated

h. Obtain a vascular surgery consultation if indicated

i. Obtain and/or record the ejection fraction

j. Screening for need to use intra-aortic balloon pump (IABP)

k. Screening using epiaortic echo as indicated

l. Document that the patient did not take anticoagulation medications (clopidogrel/warfarin) in the 5 days before the operation

2. Operative documentation:

a. Did the patient receive the correct dosing of beta-blocker (pre-op)

b. Was there correct use of intra-aortic balloon pump (pre-op -->post-op)

c. Did the patient receive appropriate and timely pre-op antibiotics within 60 minutes of incision; if Vancomycin within 120 minutes)

d. Record any blood cardioplegia (on-pump patients)

e. Document epiaortic echo of the ascending aorta and the peer consult

f. Obtain and record intra-operative hyperglycemia screening

g. Apply correct insulin management (as indicated; per protocol)

h. Use of LIMA (left internal mammary artery) for LAD (left anterior descending)

grafting

3. Post-Operative patient documentation:

a. Anteroapical MI within prior 7 days: post-op echo

b. Monitoring for atrial fibrillation for >48 hours

c. Anticoagulation therapy (as indicated)

d. Were antibiotics administered post-op for 24-48 hours

e. Was aspirin given six hours post-op or 24 hours post-op

f. Was a beta-blocker given within 24 hours post-op

g. Was a statin administered post-op

h. Document any surgical debridement and revascularization of any sternal wound infection

i. Obtain a plastic surgery consult regarding ongoing management of sternal wound

j. Tobacco screening and counseling

4. Discharge documentation:

a. Referral to cardiac rehabilitation

b. Discharge medications (e.g., beta-blocker)

c. Discharge medication: aspirin

d. Discharge medication: statin

5. Post-Discharge documentation:

a. Is the patient correctly taking beta-blocker?

b. Is the patient correctly taking aspirin?

c. Is the patient correctly taking statin?

d. Is the patient correctly administering anticoagulant?

e. Did patient resume smoking?

f. Is the patient enrolled in cardiac rehabilitation?

Gisinger calls this new program “ProvenCare.” That is because the 40 items on their check list are supported by medical evidence. Imagine that…design protocols based on evidence and follow them to get better results.

According to a story about Geisinger in the NY Times, the system was only documenting the performance of all 40 steps 59% of the time before implementing ProvenCare. Now an operation is cancelled if any of the pre-operative measures have not been done. Recently, Geisinger’s surgical teams have had scored 100% in following the recommended steps before, during and after surgery. And it has paid off in terms of reducing complications:

• 35% of patients had any type of complication after compared with 39% before ProvenCare
• Only 16% of patients required supplemental blood products compared with 23% before
• 19% of patients were not able to be discharged directly to their homes before the program; only 9% after
• There were fewer readmissions within 30 days, fewer pulmonary complications, fewer re-operations for bleeding, fewer readmissions to the ICU, and a lower in-hospital death rate (in fact, it was 0 after implementing the program.

So how does the warranty work? Geisinger charges a fixed fee for the surgery and half of the historical costs of related care provided in the ensuing 90 days. If the patient has to be readmitted, Geisinger absorbs the costs. If they do a great job and there are no problems, they have a larger profit. Now that is aligning financial incentives with good patient outcomes.

Geisinger is developing similar approaches for other types of medical care, such as hip replacements. It will be interesting to see how far and how fast they are able to go with this new model. I hope this is not a one-shot wonder. The concept of standing behind your work by offering a warranty could prove to be a powerful driver of health care quality improvement and patient safety.

Great work, Geisinger

Pat Salber, MD

Remember how shocked we were when we first heard about Dr. Moon and Dr. Realyvasquez. These are the heart doctors who performed unnecessary cardiac procedures, including coronary artery bypass surgeries, at a Tenet Hospital in Redding, California.

These guys may have been at the far end of the spectrum when it comes to driving inappropriate cardiac care, however, a study in the March 7, 2007 issue of JAMA adds to the growing body of evidence that suggests that cardiac procedure rates are strongly influenced by competitive market dynamics and not just patient need.

A group of well-respected health services researchers, led by Brahmajee Nallamothu at the University of Michigan Medical School took a careful look at the impact of introduction of specialty heart hospitals in geographic areas that represent distinct markets for tertiary (advanced) cardiac care. As opposed to general hospitals, specialty heart hospitals provide services for, and generate revenue from, a narrow spectrum of diseases.

Some health policy gurus have argued that such specialization could lead to greater efficiency and better quality of care. However, others worry that adding excess capacity could drive demand, particularly if the owners of the hospitals are doctors in that same specialty. It doesn’t take a brain surgeon to understand that filling beds, operating rooms, and catheterization labs with high revenue patients is better for the bottom line than leaving them unused.

Of course, it is possible that new specialty hospitals would just compete with existing facilities in general hospitals, taking volume from them, but keeping the overall rates of services the same. But that doesn’t appear to be what happens when one of these cardiac specialty hospitals opens in a community. Instead, the JAMA study documents that there is an incremental increase in the number of coronary revascularization procedures performed after a specialty heart hospital opens. Capacity increases and more people get these procedures.

Now this study doesn’t prove that all of this capacity was supply-driven. In fact, some of the increase may be due to meeting unfilled need. The researchers tried to understand if this was indeed what was happening by comparing what occurred when a general hospital increased its capacity compared to what happened when capacity is increased via the opening a new specialty heart hospital. What they found was a greater increase in certain cardiac procedures in communities with a new heart hospital compared to those communities with a new cardiac program at a general hospital.

Of note is the finding that there is no increase in the number of PCI (percutaneous coronary interventions) in the subset of heart patients who might benefit most from that procedure (those coming into the hospital because of a heart attack), but there was a dramatic increase in the number of PCIs being done for individuals not having heart attacks, a situation in which there may be more discretion in deciding whether to do the procedure or not.

For all of you who think, more is better when it comes to health care, I suggest you read about Drs. Moon and Realyvasquez. They had some of the highest rates of coronary procedures in the country, but some of their patients would have been better off with nothing at all.

Pat Salber

USA Today reports that newly minted heart surgeons are having a hard time findings jobs. According to an article in the Annals of Thoracic Surgery, 12% of 88 cardiothoracic residents surveyed, received no job offers in 2004. Bummer. It takes 10 years of training after med school to become a heart surgeon. Not so long ago, cardiothoracic surgery was a ticket to an exciting and lucrative career.

A major reason for the decline in CV opportunities is a change in the way heart disease is treated. More and more folks with coronary artery disease are having stents placed by cardiologists instead of chests cracked by CV surgeons. That’s a good thing, right?

The story might be even better if we spent as much energy and money on primary prevention of heart disease (you know, healthy diet and vigorous exercise on a regular basis) as we do on treating the end-result of too much fat, too many cigarettes, and too little movement. Oh, well. I think we’ll get there eventually.

Meanwhile, never fear, all you unemployed CV surgeons, the article points out that older heart surgeons are bound to retire soon and us boomers are entering our prime heart disease years. Keep those scapels sharpened.