Name: Kristy Kratz

Student Number: 0188626

Term paper for Health Economics, Econ 339

Does Providing Recommended Treatments Equal Low Mortality Rates? A Comparison of HCAHPS Data in Three Baltimore Hospitals

Abstract: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey, is a standardized

survey instrument for measuring patients’ perceptions of their hospital experience. In addition to the HCAHPS

survey, the Hospital Compare website was created through the efforts of the Centers for Medicare & Medicaid

Services (CMS). Hospital Compare shows the responses from the HCAHPS surveys and also displays rates for

Process of Care measures and Outcome of Care measures. I selected three similar facilities in the Baltimore area

to compare the HCAHPS data: Franklin Square Hospital Center, Good Samaritan Hospital, and Johns Hopkins

Bayview Medical Center. Based on my review of the data, there is no way to tell if the providing recommended

treatments equal low mortality rates. Data corresponded both negatively and positively with mortality rates in

different hospitals.

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1.0 Introduction

Beginning in 2002, through extensive analyses, consumer testing, and numerous field tests,

CMS partnered with the Agency for Healthcare Research and Quality (AHRQ), another

agency in the federal Department of Health and Human Services, to develop and test the

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey, a

standardized survey instrument for measuring patients’ perceptions of their hospital

experience. HCAHPS has provided a national standard for collecting and publically

reporting information, enabling consumers to have valid comparisons of hospitals locally,

regionally and nationally. In addition to the HCAHPS survey, the Hospital Compare website

was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an

agency of the U.S. Department of Health and Human Services (DHHS), along with the

Hospital Quality Alliance (HQA). The information on the website can be accessed by

anyone, including patients needing hospital care. Hospital Compare shows the responses

from the HCAHPS surveys and also displays rates for Process of Care measures and

Outcome of Care measures. The Process of Care measures show whether or not hospitals

provide recommended treatments for patients being treated for serious conditions, such as

heart attack, heart failure, and pneumonia. The Outcome of Care measures consist of 30-

day risk-adjusted death rates, which are compared to the National Averages. Hospitals

voluntarily submit data from medical records about the treatments their patients receive

for these conditions. According to the Hospital Compare website, measuring the

percentages of times certain recommended treatments are given, mortality rates, and

patient experiences are all ways to measure the quality of care a hospital provides. Now

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that we have been given the tools to measure the quality of care for our hospitals in three

different ways, let’s see if they are consistent.

2.0 Survey Background

The HCAHPS survey is administered to random samples of adult patients across varying

medical conditions between 48 hours and six weeks following discharge. The survey asks

patients 18 questions about their hospital stay, and publically reports results on 10

measures (communication with nurses and doctors, the responsiveness of hospital staff,

the cleanliness and quietness of the hospital environment, pain management,

communication about medicines, discharge information, overall rating of hospital, and

would they recommend the hospital). The patient survey portion of the HCAHPS data is

adjusted based on the type of survey completed (phone, paper, etc.) because phone surveys

for example usually yield higher return rates and higher scores. The survey is not yet

federally mandated, but hospitals that fail to report on the required quality measures may

receive an annual payment update that is reduced by 2.0 percentage points, so there is a

substantially large incentive for hospitals to participate. Although CMS instituted the

survey in October of 2006, the first public reporting of HCAHPS results occurred in March

2008, so the survey is not yet widely known.

2.1 Process of Care Measures

The hospital process of care measures include seven measures related to heart attack care,

four related to heart failure, seven related to pneumonia care, seven related to surgical care

improvement, and two related to asthma care for children only. For the purposes of this

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paper, I used only two measures each from three categories: one from heart attack care,

heart failure and pneumonia care. All data was taken from information reported from July

2007 through June 2008. The reason I chose these three are because every year around 5

million people suffer from either a heart attack, pneumonia or heart failure and they are

among the leading causes of hospital admissions for Medicare beneficiaries, age 65 and

older. Also, as you will see later, the outcome of care measures only includes mortality

rates for these three illnesses.

“A heart attack happens when the arteries leading to the heart become blocked and the

blood supply is slowed or stopped.“ (hospitalcompare.hhs.gov). Relating to heart attack

care, the two measures I compared were percent of patients given aspirin at arrival and

those given it at discharge. These two measures are important because aspirin can help

helping dissolve blood clots that may have formed and helps get oxygen through blood

vessels easier. If given upon admission, this could reduce the severity of the heart attack

and given upon discharge, can help prevent blood clots from forming.

“Pneumonia is a serious lung infection that causes difficulty breathing, fever, cough and

fatigue.” (hopsitalcompare.hhs.gov). With respect to pneumonia patients, the two

measures I chose to compare were the percent of patients given oxygenation assessment

and the percent of patients given pneumococcal vaccination. Pneumonia can lower the

oxygen in the blood stream because the air spaces in the lungs fill with mucus. Measuring

the amount of oxygen in the blood within 24 hours of arriving to the hospital is important

to know if oxygen therapy is needed. The pneumococcal vaccine has been known to help

lower the risks of pneumonia caused by bacteria.

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“Heart failure is the weakening of the heart’s pumping power. With heart failure, your

body doesn’t get enough oxygen and nutrients to meet its needs. “

(hospitalcompare.hhs.gov). In the category of heart failure, I compare the percent of heart

failure patients given discharge instructions and the percent of heart failure patients given

an evaluation of the Left Ventricular Systolic (LVS) function. Because heart failure is a

chronic condition, giving discharge instructions is important to help reduce the risk of

recurring illness. The evaluation of the LVs test is important to determine how the heart is

pumping and can help determine what area of the heart is affected.

2.2 Outcomes of Care Measures

The hospital outcome of care measures consist of the 30-day risk-adjusted death rates for

heart attack, heart failure and pneumonia at different hospitals. Comparing the mortality

rates with the U.S. National rates and the state rates can help understand whether a

hospital is doing a good job or not. Having the rates risk-adjusted indicates they are

adjusted based on how sick the patient was when they were admitted to the hospital.

2.3 Hospitals

The Hospital Compare website has information from over 45 hospitals in Maryland and

4500 in the United States available for comparison. I attempted to choose three similar

facilities in the Baltimore area to compare: Franklin Square Hospital Center, Good

Samaritan Hospital, and Johns Hopkins Bayview Medical Center. For basic statistics, see

Table 1.

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3.0 Assessment

Using the hospital compare website, I pulled process of care data on the three hospitals and

developed a graph, see Table 2 and Figure 1. With the exception of “Percentage of Heart

Failure Patients Given Discharge Instructions” all percentages were fairly high with

compliance of giving the recommended treatments. With respect to the percentage of

heart failure patients given discharge instructions, the numbers were low, ranging from

62% to 74% compliance, but yielded lower mortality rates for heart failure than for heart

attack or pneumonia, representing a negative correlation. For example, Good Samaritan

Hospital had the lowest percentage of compliance with giving discharge instructions, but

had the lowest mortality rate. However, John’s Hopkins Bayview Medical Center was the

least compliant with giving pneumonia patients oxygenation assessments and they had the

highest mortality rate associated with pneumonia, showing a positive correlation. Figure 3

shows the gaps in mortality rates and the process of care data graphically together.

According to the survey, none of the hospitals had mortality rates for heart attack, heart

failure or pneumonia that were “statistically different” than the U.S. National Rate.

However, I think it’s important to note that all mortality rates were below the U.S. National

Rates for all three hospitals in each category with the exception of Good Samaritan hospital

with heart attack mortality (Figure 2). With regard to the survey of patients’ hospital

experiences, Table 3 and Figure 4, all three hospitals scored lower than both the Maryland

average and National averages for room and bathroom cleanliness. In reviewing the two

areas that have higher scores for Good Samaritan Hospital, in both areas, it appears that

room cleanliness is related to whether or not patients would recommend the hospital.

What was most surprising to me to see was that the average for Maryland was lower than

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the average National averages in ALL areas surveyed. Overall, patients are most likely to

recommend Good Samaritan Hospital over the other two.

4.0 Conclusion

Based on my review of the data, there is no way to tell if the providing recommended

treatments equal low mortality rates. Data corresponded both negatively and positively

with mortality rates in different hospitals. This could be because of case mix,

demographics, location of the facility, etc. Although the surveys are risk-adjusted, the

question remains of how to do you judge a hospital as efficient or good? Each of these

measures by themselves didn’t seem to be consistent, but maybe by combining the

different methods, the consumer can make a more informed decision. Although the effort

is intended to “make important information about hospital performance accessible to the

public and to inform and invigorate efforts to improve quality” (hopsitalcompare.hhs.gov),

I think the ultimate goal is to move towards a pay for performance rating system. The

information is useful to have, but it doesn’t appear that organizations that follow the

procedures of care recommended are achieving the outcomes they should be. Another

problem with HCAHPS is that most professionals don’t know about the information. It

would be difficult for patient’s to make more informed decisions about their healthcare

based on this unless it is made more publically aware.

References

Franklinsquare.org. Franklin Square Hospital Center, Baltimore, MD. Retrieved May 2, 2009.

http://www.franklinsquare.org/documents/2008%20Annual%20Report.pdf

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Goodsam-md.org. Good Samaritan Hospital, Baltimore, MD. Retrieved May 2, 2009.

http://www.goodsam-md.org/body.cfm?id=185

Hcahpsonline.org. Centers for Medicare & Medicaid Services, Baltimore, MD. Retrieved April 30, 2009.

http://www.hcahpsonline.org

Hopkinsmedicine.org. Johns Hopkins Medicine, Baltimore, MD. Retrieved May 2, 2009.

http://www.hopkinsmedicine.org/about/statistics/clinical.html

Hospitalcompare.hhs.gov. U.S. Department of Health and Human Services, Baltimore, MD. Retrieved

April 30, 2009. http://www.hospitalcompare.hhs.gov

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Appendix

Table 1

Basic Stats Franklin Square Hospital Center

Good Samaritan Hospital

Johns Hopkins Bayview Medical

Center

Licensed beds 380 346 333

Annual Net Operating Revenue $ 412,506,000.00 $ 247,000,000.00 unknown

Annual Patient Admissions

30,209

18,064

23,180

Annual Inpatient Days

109,117

96,135

97,690

Table 2

Process of Care Measures Franklin Square Hospital Center

Good Samaritan Hospital

Johns Hopkins Bayview Medical

Center

Percentage of Heart Attack Patients Given Aspirin at Arrival 96 96 98

Percentage of Heart Attack Patients Given Aspirin at Discharge 98 95 100

Percentage of Pneumonia Patients Given Oxygenation Assessment 100 98 100

Percentage of Pneumonia Patients Given Pneumococcal Vaccination 90 95 80

Percentage of Heart Failure Patients Given Discharge Instructions 74 62 71

Percentage of Heart Failure Patients Given an Evaluation of LVS Function 96 96 95

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Table 3

Survey of Patients' Hospital Experiences

Franklin Square

Hospital Center

Good Samaritan Hospital

Johns Hopkins Bayview

Medical Center

Average for

Maryland

Average for United States

Percent of patients who reported:

That their nurses ALWAYS communicated well 74 74 71 71 74

That their doctors ALWAYS communicated well 77 79 78 77 80

That they ALWAYS received help as soon as they wanted 57 53 53 55 62

That their pain was ALWAYS well controlled 68 66 63 66 68

That staff ALWAYS explained about medicines before giving it to them 61 56 57 55 59

Reported that their room and bathroom was ALWAYS clean 57 62 59 63 69

That the area around their room was ALWAYS quiet at night 47 55 47 52 56

YES they were given information about what to do during their recovery at home 85 82 83 78 80

YES they would definitely recommend the hospital 64 73 65 64 68

Percent of patients who gave their hospital a rating of 9 or 10 on a scale from 0 - 10 (10 highest) 62 59 62 59 64

Key:

Better than Average for MD

Same as Average for MD

Worse than Average for MD

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Figure 1

Figure 2

0

20

40

60

80

100

120

Franklin Square Hospital Center

Good Samaritan Hospital

Johns Hopkins Bayview Medical Center

15.4

8.8 8.7

17

8.6 8.5

14.1

10.39

16.1

11.4 11.1

0

2

4

6

8

10

12

14

16

18

Heart Attack

30-Day

Mortality

Pneumonia

30-Day

Mortality

Heart Failure

30-Day

Mortality

Franklin Square HospitalCenterGood Samaritan Hospital

Johns Hopkins BayviewMedical CenterAverage for United States

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Figure 3

Figure 4

47

52

57

62

67

72

77

82

87