Cardio care is a growing margin contributor for hospitals and health systems. That's why healthcare providers are retooling in a big way to develop cardiac care subspecialty programs.
This article appears in the July/August issue of HealthLeaders magazine.
With cardiology among the fastest growing service lines, hospitals are retooling in a big way to win market share by developing cardiac care subspecialty programs that will give them a competitive edge in a flourishing market.
Already, cardio care is a significant and growing margin contributor for hospitals and health systems, with 76% reporting positive margins for cardio and 66% expecting this service line margin to increase over the next three years, according to the March HealthLeaders Media Intelligence Report, Reshaping the Cardio Service Line for Population Health and Reform Challenges. Yet hospitals believe they must tweak their existing programs to create differentiators that will lure more patients in need of greater specialization of care.
Creating multidisciplinary teams with advanced specialties is an important component of wide-ranging heart programs that reach a broad patient population. Faced with more elderly patients who have chronic conditions, hospitals are initiating changes to provide specialized care that will save patients, using what David Wohns, MD, medical director of the cardiac cath labs and interventional cardiology program for Spectrum Health System in Grand Rapids, Mich., calls "a bridge to recovery." Spectrum Health has nine hospitals, 130 ambulatory and service sites, and 1,938 licensed beds.
"There are new technologies, pumps and assistive devices that can be applied percutaneously or surgically placed. Because of percutaneous procedures, we are able to save people who are very sick, and five years ago they couldn't survive," says Wohns. "It may be a percutaneous device placed in the cath lab or surgically placed in the operating room as that bridge to recovery."
Spectrum has developed a broad swath of programs to improve care, ranging from the development of a transplantation program and ventricular assist device program to a multidisciplinary shock team for critically ill patients.
As a result, surgery volumes at the hospital's Frederik Meijer Heart & Vascular Institute have far exceeded the average for hospitals that are members of the Society of Thoracic Surgery. In 2012, Meijer's bypass surgery volume reached 411, compared to 155 for the average STS member. It handled 444 valve surgeries, compared to 67 for STS.
Within the hospital system itself, Spectrum has greatly increased patient volumes in subspecialties. Its ventricle assist device implant volumes increased from four in 2009 to 48 in 2012, and its heart transplants increased from two in 2010 to 20 in 2012. In the meantime, its heart failure readmissions—at 23% in 2012—were favorable compared to the national average of 24.8%, based on Medicare data about patients discharged between July 1, 2007, and June 30, 2012.
Hospitals are seeking better market share in cardio specialties and subspecialties to improve care and realize increased ROI. New endovascular procedures are emerging as patients want the benefits of reduced trauma compared to open procedures and the faster recovery associated with minimally invasive surgery and interventional procedures.
Cardio specialties are related to general heart care and vascular surgery, while subspecialties refer to specific cardiac programs, including internal and critical care medicine, interventional cardiology, pulmonary disease, heart failure, cardiovascular disease, transplants, adult congenital heart disease, and others. The American Board of Medical Specialties certifies specialties and subspecialties.
The 437-licensed-bed University of Colorado Hospital in Aurora is expanding programs for congenital heart disease, finding an increased need for specialization. UCH also is among a growing number of organizations working to increase patient volumes by developing advanced subspecialty programs. It offers fenestrated endograft stents as new treatment options for abdominal aortic aneurysms, providing a service for patients who would not otherwise be candidates for traditional endovascular repairs.
The procedures have resulted in decreased complications, early discharge, and a quick return to normal quality of life, says David Kuwayama, MD, MPA, a vascular surgeon and assistant professor of vascular surgery.
"Over time, we've seen an increasing patient load and a lot more referrals for complicated aneurysm disease. There is clearly significant patient demand for minimally invasive ways to treat these problems," says Kuwayama.
More hospitals are also performing cardiac catheterizations through the radial artery, which has proven to lower the risk of vascular complications. Only about 8% of cardiac catheterizations are performed using the radial approach, but hospitals say they realize the patient benefits of transradial interventions.
The 547-licensed-bed Ochsner Medical Center in New Orleans is focusing on such cardio repairs to capture a patient market, says J. Stephen Jenkins, MD, FACC, FSCAI, associate section head for interventional cardiology and director of the cardiac catheterization laboratory. "Everything is going to minimally invasive techniques," says Jenkins. "We repair aneurysms in a minimally invasive way that 10 or 15 years ago was done surgically."
Although some hospitals are moving tentatively with subspecialties, Spectrum's Wohns says "I don't think these are a passing fad because there is increased data on reduced cost and increased patient satisfaction, increased safety and fewer adverse events. I think the trends will continue as the story unfolds, with economic benefits, too."
Spectrum and other hospitals are investing millions of dollars in hybrid ORs, which are considered an ideal setting for minimally invasive procedures that require advanced imaging. Some hospitals are using the hybrid OR to pursue innovative cardio subspecialty procedures to treat patients who are too ill to undergo traditional surgery.
One notable procedure is the transcatheter aortic valve replacement, or TAVR, says Zoltan Turi, MD, FACC, FSCAI, director of the structural heart disease program at the 493-bed Cooper University Hospital in Camden, N.J.
"Because we have access to TAVR, we have become a referral site for cardiologists who have patients they are reluctant to send to hospitals for surgery," Turi says. "The number of hospitals that use TAVR is growing. When we started, we were one of the first ones. Now there are more than 200 sites in the U.S."
The hybrid OR opens the door for such procedures.
The 442-staffed-bed St. Peter's Hospital in Albany, N.Y., is also high on hybrid ORs to improve outcomes and offer variety in cardiac care.
"We do a tremendous number of endovascular procedures and have great outcomes. The robotic equipment allows us to visualize the reconstruction of the aorta through a synchronized imaging display," says Dorothy Urschel, MS, ACNP-BC, RNFA, NEA-BC, MBA, the cardiac and vascular service line director for St. Peter's Health Partners. Urschel says the hybrid ORs have enabled minimally invasive surgeries that typically require shorter lengths of stay and faster recovery than open procedures. "Many surgeries are going to be minimally invasive."
Over the years, hospitals have been buying more and more hybrid OR suites, with a 10% growth each year over the past two years, according to the ECRI Institute, a nonprofit organization based in in Plymouth Meeting, Pa., that researches healthcare cost-effectiveness.
There is growing market pressure on hospitals to have hybrid ORs, says Thomas Skorup, FACHE, vice president for applied solutions at ECRI, as more physicians want to perform new combinations of endovascular laparoscopic surgery or open procedures in the same OR with advanced angiography image guidance. Hybrid OR suites comprise up to 100 different medical devices and systems from multiple vendors, with key technologies such as a fixed angiographic imaging system.
One of the major issues is cost. Hospitals leaders considering hybrid ORs must evaluate how they plan to use each 900- to 1,400-square-foot system in the surgical theater, and should expect hefty expenses involved, ranging from $3 million to $4 million for each suite. Because of the expense, the possibility for short-term ROI is questionable. Staff training and development are essential for the safety and efficiency of the hybrid OR, which is double the size of a standard OR, Skorup says.
Hospitals need to evaluate purchasing, pricing, and the right imaging system to meet the different needs of their organizations, Skorup says.
"I've seen institutions making great investments in technology like the hybrid OR or cath lab or interoperative MRI," he says. There are some instances, however, where hospitals are saying, 'We aren't using them as much as we would have expected,' " Skorup says.
Success key No. 1: Amputation prevention programs
Every year, more than 100,000 adults lose limbs due to vascular disorders, and with an aging and increasingly heavier population at risk for diabetes, more are likely to do so. Most patients at risk of losing limbs are afflicted with peripheral arterial disease, a circulatory problem in which narrowed arteries reduce blood flow to the arms or legs.
The vascular amputation program at 208-bed Metro Health Hospital in Wyoming, Mich., has focused on improving circulatory care for patients and preventing amputations, even though some recommendations for amputation originated with patients' primary care physicians.
J.A. Mustapha, MD, director of Metro Health's endovascular intervention, heads the hospital's vascular amputation prevention program. His specialty is performing artery and vein catheterizations designed to open vessels and improve circulation. In the process, the hospital has developed a technique to treat vascular systems successfully and in many cases avoid amputations. The treatment approach uses an ultrasound-guided interventional device through the foot and an ultrasound transducer that helps identify blood flow that traditional angiography misses. Often, medication can address this condition to prevent amputations.
When the endovascular intervention program began five years ago, the Metro Health System saved at least 88% to 92% of limbs that had been recommended for amputation. It now saves even more—96% to 98%, says Mustapha. Limb preservation care is part of Metro Health's overall work in peripheral arterial disease, an area in which patient volumes have increased dramatically at the hospital. Over the past five years, the volume of cases has increased from 67 to 827, he says.
"We are asking for more operating rooms and staff, and we are booked," he says. "We are improving care and making money for the hospital."
The hospital uses a diagnostic technique that "basically goes down around the foot area and puts a small catheter in there to take pictures. We mastered the method of clearing the vessels, have a plan of attack to follow and we stick with it," says Mustapha, adding that "it's amazing we are saving 96% of the limbs; we would have been happy saving 50%."
Physicians have referred cases to the hospital after they believed there was no other option than amputation, Mustapha says. Too often, these doctors lack superior techniques to properly evaluate areas of the leg or feet that may be impacted, he explains.
At Metro's amputation prevention program, all referred patients scheduled for amputation are seen within 24 hours. If there is no contraindication, patients will then undergo peripheral angiography within 48 hours.
Primary care physicians often rely on "conventional angiograms that do not detect blood flow below the knee," Mustapha explains. As a result, "these physicians see a brick wall and believe there is nothing else to do [other than amputation]." Some physicians make a singular decision and do not make referrals for second opinions and amputations are performed. "It's a sad thing," Mustapha says.
An important key to building a successful peripheral vascular disease program is partnering with and educating the referring physicians, who include primary care providers and podiatrists, Mustapha says. Hospital peripheral interventionists visit physician offices in the field to educate primary care doctors on peripheral vascular disease screening.
Metro Health's PVD program includes collaborations with other specialists, including those involved in interventional radiology, cardiology, vascular surgery, and wound healing. Patients are instructed about healthful practices, including the need to quit smoking, follow a reasonable diet, and exercise.
The hospital's program began after Mustapha counseled a 52-year-old patient with severe PAD in her leg. Mustapha made the connection that a device commonly used to clear clogged arteries leading to the heart could be adapted for PAD. "It opened the door to what we are doing. This created a cascade of events that have been successful beyond what we thought possible," Mustapha says. "Patients are so grateful when we are saving a limb. Ironically, when we save their lives, they aren't as expressive."
Success key No. 2: Congenital heart disease
For years, children were the primary focus of congenital heart care. But many youth afflicted with congenital heart disease are now living past 18 years, which translates into an increased need for treating them as adult patients. However, only 10% are seeking appropriate care from adult congenital cardiologists, according to the Adult Congenital Heart Association. More than 1 million adults in the United States live with congenital heart disease.
"Probably the majority of these adult congenital patients who are seeking cardiology care are in pediatric care still," says Joseph Kay, MD, program director of the University of Colorado Hospital adult congenital heart disease program. "So a pediatric cardiologist who followed them throughout their lives is still managing them, through adulthood in the U.S. But it's not the ideal scenario."
UCH is finding a niche market by improving care for adults and children, says Kay.
Unlike many hospitals, UCH has both a pediatric program and an adult program for former pediatric patients. Kay, for instance, is qualified in both adult and pediatric care. There are now 1,200 people enrolled in the UCH program, which has added 200 patients a year over the past several years, he says. "We're almost at capacity, for the number, in our facility."
It's important to have an effective adult congenital multidisciplinary team to treat older patients, Kay says. In many instances, pediatric physicians are continuing to treat older patients into adulthood, but there are gaps in care, he says.
Congenital defects occur in about 1 in 120 births, according to the ACHA. Surgical repairs and other interventions are allowing babies born with serious congenital heart defects to live into adulthood. "The survival rate for children has gone up exponentially," about 95% to 98%, Kay says. "Children who never survived into adulthood a decade ago are now surviving in large numbers."
At least 75% to 80% of patients with congenital problems are not cared for in adult congenital heart centers, he adds. "Many of the [adults] are not receiving care at all. Many of them have the false impression that they were fixed as children. We believe there is an absolute need for practitioners in the field, and the field is going to continue to grow."
There is also is a growing need for follow-up care in an adult congenital heart subspecialty, Kay says. Survivors have a greater risk than other people of developing additional heart problems because of changing blood flow patterns in the heart. Long-term problems include rhythm disturbances, valve problems, heart failure, endocarditis and stroke.
Adult patients require the skills of a clinical team with experience in adult comorbidities, such as diabetes or hypertension, and can offer guidance about employment, pregnancy, and physical activity, Kay says. Adult patients who seek care in adult congenital heart centers report fatigue, exercise intolerance, chest pain, shortness of breath, or palpitations.
"Many adult congenital programs hadn't existed until the past few years," Kay says. "So many adult cardiology specialists had little or no exposure to patients and lacked the experience in understanding how to give them true optimal care." In December, the American Board of Medical Specialties created a physician certification in adult congenital heart disease as a subspecialty, which may increase the number of cardiologists who gain an expertise in that area, Kay says.
Success key No. 3: Atrial fib
Atrial fibrillation is a serious heart rhythm abnormality seen by physicians. It is marked by a rapid, irregular heartbeat originating in the small, upper chambers of the heart. If not treated effectively, it can lead to stroke, serious bleeding, cardiac arrest, and death.
Most people with atrial fibrillation have identifiable risk factors, such as high blood pressure or structural heart disease, and tend to be over age 60. About 6 million American adults have been diagnosed with atrial fibrillation or an irregular heartbeat. "It's not going away and it's on the rise," says Andre Gauri, MD, electrophysiologist with the Spectrum Health's heart and vascular program.
At Spectrum Health, over the years, many patients have been admitted for afib observation. As the country moves toward value-based care, this practice has been questioned, and Spectrum is one of many hospitals that realized its protocol of hospitalization for observation was unnecessary, Gauri explains.
As a result, Spectrum developed a dedicated atrial fibrillation clinic to improve evaluation of afib and improve care, Gauri says. The clinic team includes five board-certified electrophysiologists, six electrophysiology RN case managers, and two electrophysiology midlevel providers.
Spectrum realized that, until recently, "we were admitting patients essentially to do an outpatient workup half the time," Gauri says. "All these patients would get admitted to the hospital, get a whole bunch of tests, go home, and then follow up as an outpatient."
Instead, "if a 45-year-old patient with no prior history of severe cardio problems develops a rapid heartbeat, she can be put in the observational unit and then followed in the afib clinic within 48 hours, and other tests are done," Gauri says.
By utilizing the clinic, Spectrum has increased its volume of procedures, including afib ablations, which increased from 270 in 2009 to 400 in 2011. Ablation is a procedure used to treat arrhythmias. The type of arrhythmia determines how ablation would be performed. Evaluations of supraventricular tachycardia, a common heart rhythm disturbance where the heart beats faster than it should, increased from 500 in 2009 to 550 in 2011. At Spectrum, other evaluations—such as premature ventricular contractions, a cause of irregular heart rhythms—increased from 25 to 50 from 2009 to 2011.
Patients are seen and evaluated within three days of referral. The clinic also provides a timely response for monitoring mediation therapy and devices.
"There's a large variety of ways to treat afib," says Gauri. "At least 15% to 20% of procedures can be medically stabilized in a 24-hour observational unit, and that won't count for hospital admissions. In the beginning, there was some pushback about the unit, but now physicians are seeing the value."
Success key No. 4: TAVR program
Although open-heart surgery, also known as surgical aortic valve replacement, has been considered the standard for replacing aortic valves for severe aortic stenosis, some elderly and frail patients with varied complications are physically unable to withstand the procedure.
As a result, more hospitals are trying to fill that gap by providing transcatheter aortic valve replacement, or TAVR, as alternative treatment for aortic stenosis, says Turi, director of the Cooper University Hospital center.
Aortic stenosis and aortic valve disease affects nearly 300,000 Americans, and that is expected to increase significantly over the years, Turi says. "As the population ages, aortic stenosis is going to be more and more prevalent and it will be more of a problem for healthcare," Turi says. With aortic stenosis, "there's wear and tear on the heart valve, like pitchers' arms," he says. "The valve is full of calcium and it creaks open rather than flies open."
With conventional aortic valve replacement, surgeons make an incision in the chest, stop the heart, put the patient on a heart-lung bypass machine, and remove the old valve replacing it with a new one. They then restart the heart and sew up the chest.
With TAVR, the new valve is placed inside the old valve while the heart is still beating and deployed with the aid of a balloon that pushes aside the old valve and allows the new valve to expand into place. The valve is introduced through a puncture in an artery in the leg or through a small incision made in the side of the chest.
People who have symptomatic aortic stenosis have a mortality rate as high as 50% in one year. With TAVR, people who have had previous chest or heart surgeries, severe lung disease, chest radiation, or other serious medical conditions have another chance to live better and longer lives, Turi says.
With TAVR, Turi says, "There's a less invasive procedure and patients tolerate it better. It's much easier on the patient."
Cooper University Hospital is now involved in clinical trials named PARTNER (Placement of Aortic Transcatheter Valve), which evaluated TAVR. According to the findings of PARTNER studies in 2011 and 2012, there was comparable or even favorable quality and efficiencies for the procedure compared to open surgery. In a study known as PARTNER B, survival for patients at one year was significantly higher with TAVR (69.3%) compared to patients who received other therapy (49.3%). The trial included 380 patients in 21 hospitals and academic facilities in the United States, Canada, and Germany.
TAVR patients also had fewer hospitalizations and better symptom relief than did those receiving standard medical care. The University of Colorado Hospital also participated in the PARTNER trials, says John Carroll, MD, director of cardiac interventions at the UCH. TAVR is among the "novel therapies [that] are really transforming [cardiovascular care]," he says.
Implementing TAVR in hybrid ORs requires a special team approach, says Turi. "Sites that have succeeded need a strong working relationship among multiple disciplines," he says."
Like the hybrid OR, the solutions hospitals pursue for cardiology subspecialties are apt to be hybrid—known for their adaptability, efficiency, and efficacy in care as the population of patients needing this kind of treatment soars.
Reprint HLR070813-7
This article appears in the July/August issue of HealthLeaders magazine.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
