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Teaching hospitals challenge low safety ranking by Medicare

Data may affect financial incentives

Medicare’s first public effort to identify hospitals with patient safety problems has pinpointed many prestigious teaching hospitals in Boston and around the nation, raising concerns about quality at these places but also bolstering objections that the government’s measurements are skewed.

Massachusetts General Hospital and Beth Israel Deaconess Medical Center, both affiliated with Harvard Medical School; and Boston Medical Center, affiliated with Boston University, were among those having substantially more complications than the average hospital, according to data evaluated by the Medicare program.

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But leaders of a number of the nation’s major teaching hospitals are questioning the accuracy and fairness of the data, saying they do not properly account for how severely ill their patients are. The numbers were compiled as part of a series of efforts by the government to judge - and ultimately pay - hospitals on the quality of their care.

Similar objections followed previous phases of the government’s plan to tie Medicare reimbursement to metrics - a central tenet of the 2010 federal health law. The administration believes adding such financial incentives into Medicare, the nation’s largest insurer covering 47 million seniors and disabled, will entice hospitals to lower costs and improve care.

Starting in October, hospitals with poor patient-satisfaction ratings or high rates of readmissions will lose money, despite hospital concerns about the way Medicare is making those judgments. Medicare could add the safety measures into its payment formula as soon as October 2013.

Medicare is publishing the information on its Hospital Compare website (www.hospitalcompare.hhs.gov), and some insurers may factor it into decisions on how much to pay hospitals.

But the reservations raised about the patient safety measures are notable because they are echoed by a number of independent specialists, 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, recommended against using the patient safety measure in the hospital payment formula because of “concerns about the reliability of the data sources.’’

Officials at many of the hospitals listed as having high rates of complications say the measures exaggerate problems at hospitals that treat many complicated cases or very sick patients.

“Not all of these metrics are ready for prime time,’’ said Dr. 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.

The data show high rates of serious complications for elderly patients at about 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 about 10 times as likely as other hospitals to have high complication rates, according to a Kaiser Health News analysis.

The data cover just Medicare patients, but the government believes they are indicative of a hospital’s overall quality. Medicare calculates each hospital’s overall 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 calculations factor in the different mix of patients, “leveling the playing field for comparisons.’’

But Dr. Donald Goldmann, a senior vice president at the Institute for Healthcare Improvement in Cambridge, said Medicare billing records - the basis of the patient safety evaluations - are not refined enough to distinguish between the levels of illness and health problems among patients.

Dr. Gregg Meyer was one of the people who helped create the formulas a decade ago when he was working at the federal Agency for Healthcare Research and Quality. Now in charge of patient safety at Massachusetts General Hospital, a Harvard teaching hospital, he said he looked into Medicare’s report of high rates of complications for his hospital and found no actual harm occurred.

“They were supposed to be hypothesis-generating,” he said of the patient safety indicators. “It is to my horror that they are used to create conclusions. Using this as a mechanism to report something conclusive about safety is what we would term politely an off-label use.”

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 that train no physicians or just a handful of them — were flagged as having high rates.

Barbara Rudolph, senior scientific 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.”

But Dr. Stanley Hochberg, Boston Medical Center’s chief quality officer, said the hospital, affiliated with Boston University, had found no pattern of residents causing more complications than licensed surgeons. He said the hospital has dedicated teams working to reduce blood clots, infections, and other problem areas in patient safety.

According to the Medicare data, patients at Beth Israel Deaconess, Mass. General, and Boston Medical Center had more accidental cuts and tears than did those at most hospitals.

Dr. Kenneth Sands, senior vice president in charge of quality at Harvard-affiliated Beth Israel Deaconess, said: “We have looked at the circumstances of those events and we don’t feel that there’s a patient safety risk.” He added that Medicare’s mortality data show Beth Israel Deaconess does better than most hospitals in keeping patients from dying.

Hospital Compare shows Beth Israel Deaconess did better than most hospitals on several other patient safety measures, with fewer accidental deaths of patients and fewer post-surgical breathing failures. Mass. General also had fewer breathing failures after surgery than did most hospitals, the data show.

Baystate Medical Center in Springfield, affiliated with Tufts University’s medical school, was the only major teaching hospital in Massachusetts with fewer complications than the national average. Dr. Evan Benjamin, Baystate’s senior vice president for quality, said “the use of the data to compare one institution to another is flawed.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research organization.
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