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Heart Attack Care: Why Finding the Best Hospital Makes a Big Difference

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Check in to a five-star hotel for a weekend getaway and you'd expect far better service than you got at the one-star lodge you stayed at for Uncle Charlie's funeral. But rushing to hospital with a potentially deadly heart attack, you might not give the matter of hospital quality a second thought. But you should. It could determine whether you see any more weekends -- at all.

Squeezed between rising costs and falling revenues, America's 5,000 hospitals are in pain. In 2009 about one-half lost money for at least part of the year. [1] Many still do. Glaring gaps in performance are showing up between the best "five-star hospitals" and the rest. But this gap isn't measured as finesse of food -- charm of concierge. This gap is measured as life and death. And web-based information groups are blowing the lid off hospital performance secrets -- showing in stark terms exactly what happens when patients check in to the best, and worst, establishments. In October, HealthGrades published their annual quality study. Two weeks later Thompson Reuters announced the top 50 U.S. hospitals for heart care; last week, Leapfrog posted their Annual Top Hospitals List. Any day of the week, government-run Hospital Compare lets you check performance ratings for hospitals in your area.

Does all this transparency help? Are there real differences between hospitals in the same way there are differences in hotels? Does it matter where the ambulance takes a heart attack patient? The short answer, you bet.

Off the bat, it impacts a lot of people. The American Heart Association says 935,000 are hit by heart attacks each year in this country. That's two every minute, 24-hours a day, 7-days a week. About 700,000 get to the hospital. So what? Does it matter which hospital?

The good news is that most heart attack patients who get to hospital live to go home -- 92 percent survive to check out. [2] That score has improved over the last decades as doctors figured out what causes a heart attack (a blood clot blocking an artery that supplies the heart muscle); then what to do about it (unblock the artery with clot busters, blood thinners or heart procedures); and how fast they needed to act (survival rates are improved dramatically in patients treated within minutes of the start of chest pain).

The bad news is the massive gap in performance between the best and worst hospitals. This is where information websites are schooling savvy patients and their families -- pressing hospitals to perform or get out of the heart attack business altogether. The facts show that five-star hospitals check out 94 percent of their heart attack patients through the front door. The shocking tragedy is that one-star hospitals check out only 88 percent. The rest are carried out through the back door in a body bag. This gap holds true even when differences in the social, economic and health conditions of hospital guests at check in are accounted for. [3]

So five-star hospitals do a better job on heart attacks than one-star hospitals. But what does a 6 percent performance gap mean? Is it really a big deal in the grand scheme of U.S. health care reform?

The answer is it's a very big deal, and here are four ways to clock it:

  • First, if all hospitals reached five-star status, then 20,000 more Americans with heart attacks would go home every year looking forward to the next weekend. [4] That's one every 25 minutes.
  • Second, 6 percent fewer deaths is a bigger gain than that achieved by any new drug or device approved by the FDA for the treatment of heart attacks, ever. It's more than twice as good as breakthrough treatments like aspirin or clot busters. [5] Three-times better than stents to keep blocked arteries open; 10-times better than popping Plavix during the acute phase; and at least 12-times better than maxing out on cholesterol-lowering pills for a whole year after surviving the heart attack. [6, 7, 8] In other words, better hospitals are more important than better drugs or devices.
  • Third, the results last. Heart attack patients treated in five-star hospitals are 38 percent more likely to be alive one month later and 24 percent more likely to be alive six months later than those treated in one-star hospitals. [9]
  • And last, but by no means least, top hospitals are more efficient. Heart patients in five-star places cost $1,300 less per stay and go home a half day sooner. [10]

Washington, DC, in my opinion, can't fix this. Not even Don Berwick, the brilliant Harvard professor who practically invented the hospital quality movement at IHI -- and then was tapped by Obama to run CMS -- can change this. The work can only be done by hospitals themselves -- where CEO's, other executives, doctors, nurses, pharmacists, emergency medical technicians and innovators must roll up their white coat sleeves not as individual experts, but in multidisciplinary teams. Like a top luxury hotel, they have to perfect the pathway of care and the guest experience if they want to compete. In five-star hospitals that pathway literally runs from ambulance to cath lab in 15 minutes; and post-op routines run like clockwork until guests check out with the right meds and followup orders in 24-48 hours.

For this to function on time every time, education, training and incentives of hospital staff are aligned, metrics defined, checked and double checked constantly. New technology is not enough either, and economics matter. Real innovators improve the pathway of care without adding aggregate financial burden to cash-strapped hospitals.

Those riding with a loved one in that ambulance must demand speed, quality of action and communication from the second of arrival at the front desk to that happy day of "check out before lunch." Our best hotels give us what we want. So should all of our hospitals. Five-star treatment for heart attacks please -- everywhere, now.

Sources:
[1], [10] http://thomsonreuters.com/content/press_room/healthcare/TRStudyTracksRecessionHospitals
[2], [3], [4], [9] HealthGrades
[5] ISIS­-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS­2. Lancet 1988;ii:349­60.
[6] Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361:13-20.
[7] Sabatine MS, Cannon CP, Gibson, CM et al. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 2005; 352:1179-1189
[8] Cannon CP, Steinberg BA, Murphy SA et al. Meta-analysis of cardiovascular outcomes trials comparing intensive versus moderate statin therapy. J Am Coll Cardiol 2006;48:438-45

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