Evaluating Quality of ‘Medical Tourism’ For Heart Surgery: Measures That Matter

Michael Schlosser, MD
Felix Lee, MD

Growing numbers of self-insured employers, especially those in rural areas, are exploring the idea of offering employees an in-country “medical tourism” option in hopes of lowering costs and improving outcomes. Sending workers out of town to another region—or even out of state—can potentially achieve both.

Coronary artery bypass graft (CABG) surgery is one of the most popular domestic medical tourism options because it’s common, expensive, and has highly variable clinical outcomes. Moreover, the outcomes for the famous, brand-name institutions don’t necessarily match up with their glitzy reputation for excellence.

The risks of choosing a poor performer are high. Costly complications can quickly erase the touted 20% to 40% savings—especially if the employer is paying separately for readmissions.

Michael Schlosser, MD

Michael Schlosser, MD

But there are some success stories. Lowe’s pioneering flat-rate deal with the Cleveland Clinic for heart surgery has shown both cost savings and quality improvement. Other large employers, notably Walmart and PepsiCo, have followed suit, signing contracts with self-described, single-hospital “centers of excellence” for a handful of elective procedures.

What matters most?

The challenge for payers shopping for a medical destination is not so much brokering a deal, but how to assess true quality and the measures that matter. What they need is a formal RFP process that captures all the relevant variables of a good outcome and weighs each variable appropriately. We now have a vast library of data on individual hospitals and how well their open heart surgery patients do. Federal and state governments, professional societies, industry associations, accrediting bodies, online review services, and consumer and trade publications—they all contribute. But only a handful of measures truly reflect clinical quality.

Felix Lee, MD

Felix Lee, MD

Here’s our short list of the measures that matter:

Mortality and readmission rates. The Hospital Compare database of CMS includes the 30-day mortality and readmission rates of CABG patients on an annual basis. It is a Medicare database, so it is limited to patients 65 and older, but the rates should be just as good—if not better—for a younger, healthier population of working-age patients. At a minimum, payers shopping for a medical tourism destination should eliminate from consideration any hospital whose rates are worse than the national average.

Chest pain center accreditation and certification by the Society of Cardiovascular Patient Care or the Joint Commission. Destinations for CABG surgery should also be able to expertly handle other potential complications, including heart attacks. Certification in this acute care arena also signifies that standardized protocols and clinical orders are in place so that all chest pain patients receive similar care and treatments. The highest designation offered by the Society of Cardiovascular Patient Care is accreditation as a chest pain center with primary percutaneous coronary intervention and resuscitation. The Joint Commission also has an option for chest pain certification that combines a review of acute myocardial infarction and acute coronary syndrome programs into one award. Both look at important quality considerations such as door-to-balloon time, transfer reaction time, and patient outcomes.

Hospital-acquired infection rates and prevention strategies. A hospital’s rate of health care–associated infections, even those unrelated to open heart surgery, is one barometer of quality that can be found in publicly available data. Before signing a direct contract for CABG surgery, three of the most important figures to examine are the facility’s rate of central line–associated blood stream infections, catheter-associated urinary tract infections, and surgical site infections. Payers should also ask about the hospital’s infection protection protocols, such as treating patients with an antibiotic such as mupirocin prior to surgery to reduce the risk of MRSA infection.

Hospital in-migration statistics. State hospital associations often track migration of patients from outside the immediate service area to hospitals in a market. In-migration can be a good indication of hospitals that patients seek out, often at the suggestion of a referring physician in their home territory.

Nurse retention. Beware of facilities with a high nurse turnover rate, as it may suggest staff dissatisfaction with current working conditions or low morale. These data are not publicly available, so they would have to be requested from facilities under consideration. Also, because staffing is a perennial problem in health care, and candidate facilities may have strategies to mitigate its impact on quality, you might want them to elaborate on how staffing challenges are being addressed.

Preoperative clinic. Good CABG programs have a preoperative clinic component that thoroughly screens patients to prevent same-day cancellations by patients who haven’t been comprehensively “optimized” for surgery. For medical tourists, the facility will likely have a standard preoperative evaluation package with a checklist of all evaluations and lab tests that need to be done by a health care provider in the patient’s home territory, the date by which results need to be received by the destination facility, and the clinical benchmarks that need to be met before a surgery can proceed as scheduled. Properly preparing patients for elective CABG surgery can involve smoking cessation and control of diabetes. Anemia, malnutrition, and poor renal function may need to be addressed. Patients should also have their target graft sites, radial arteries, peripheral veins, and thoracic arteries evaluated. Protocols for patient screening and preparation are critical to preventing complications.

Performance report cards. The Society of Thoracic Surgeons (STS) publicly reports outcomes for CABG. The STS database uses a three-star grading system, with most facilities and physicians falling in the two-star performance category based on four key quality parameters: absence of operative mortality, absence of major morbidity, use of the internal mammary artery, and receipt of required perioperative medications. A three-star designation by STS means that a facility is hitting its benchmarks for the five most serious complications of cardiac surgery: reoperation, stroke, kidney failure, infection of the chest wound, or prolonged need to be supported by a breathing machine or ventilator. Star ratings are good indicators but are only as good as the data that are entered (and it’s usually a manual abstraction process) and risk adjustment.

Healthgrades. Unlike most provider ratings and comparisons, those offered by Healthgrades evaluate quality for conditions like CABG based solely on clinical outcomes. For CABG, that means 30-day mortality rates presented on a five-star, worse- to better-than-expected performance measurement scale. Healthgrades also shares results of the multiple-question Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that measures patients’ satisfaction with their care experience, but this feature of Healthgrades reports should be heavily discounted if not ignored. Patient satisfaction scores on such factors as how well pain was controlled and how quickly help was received when requested have not been shown to correlate with overall procedural quality or success. Some studies have shown that high patient-satisfaction scores occur at facilities with higher complication rates, post-procedure morbidities, and excessive procedural mortality.

What matters less?

The internet is littered with Top 10 and Best 100 lists purporting to call out the highest performers, but before thinking of any of them as legitimate yardsticks for “quality,” first consider the origin of the data, assumptions made when they were being collected, and how the metrics themselves were created. The ones published in magazines are generally paid advertisements or based on nominations with no rigorous screening process involved. Social media sites like Yelp and Angie’s List rate health care facilities based more on opinions or bad experiences, rather than valid science.

Aggregated star rating systems and scores, such as those offered by the Leapfrog Group, also don’t get at what matters most. While its hospital survey looks at a few important factors, such as the frequency of hospital-acquired infections and “never events,” those measures are bundled with other metrics—e.g., patient satisfaction scores (from HCAHPS), and whether a facility is using computerized physician order entry, which has yet to be proven as independently associated with better outcomes.

You can’t go wrong if you stick to objective measures with real ties to quality of care. These are the metrics that point to “centers of excellence” where patients are most likely not just to survive a CABG procedure, but also remain free of complications so that they can fully participate in a cardiac rehab program and get back home—and to work—as soon as possible.

Michael Schlosser, MD, is chief medical officer of HealthTrust, a group purchasing organization in Nashville. Felix Lee, MD, is medical director of cardiovascular services at Good Samaritan Hospital in San Jose, Calif.


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