Final research paper completed in 2009 for Economics

1. 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.

2. 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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3. 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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4. 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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5. “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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6. 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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7. 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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8. 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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9. Appendix
Table 1
Johns Hopkins
Franklin Square Good Samaritan Bayview Medical
Basic Stats Hospital Center Hospital 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
Johns Hopkins
Franklin Square Good Samaritan Bayview Medical
Process of Care Measures Hospital Center Hospital 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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10. Table 3
Franklin
Square Good Johns Hopkins Average Average for
Survey of Patients' Hospital Hospital Samaritan Bayview for United
Experiences Center Hospital Medical Center Maryland 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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11. Figure 1
120
100
80
60
40
Franklin Square Hospital Center
20
Good Samaritan Hospital
0
Johns Hopkins Bayview Medical
Center
Figure 2
18 17
16.1
15.4
16 14.1
14
11.4 11.1
12 10.3 Franklin Square Hospital
10 8.88.6 8.78.5 9 Center
Good Samaritan Hospital
8
6 Johns Hopkins Bayview
4 Medical Center
Average for United States
2
0
Heart Attack Pneumonia Heart Failure
30-Day 30-Day 30-Day
Mortality Mortality Mortality
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12. Figure 3
Figure 4
87
82
77
72
67
62
57
52
47
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