Outcomes that Matter: Quality Health Care Improvements Save Lives

"By streamlining the care, we've been able to dramatically improve outcomes."
Henry Ting, M.D.

Today much is being written about quality in health care, and the need to improve what we do and how we do it. A number of organizations, including the government, have been measuring physicians and hospitals to determine if their performance is the very best it can be.

This has led to a number of pay-for-performance projects sponsored by government purchasers such as Medicare and Medicaid; large employers who purchase health care for their employees; and health care coalitions. In these projects, providers are paid for doing very specific things for patients in a very specific way, with an emphasis on the processes of care. Recently, Denis Cortese, M.D., president and CEO of Mayo Clinic, and Robert Smoldt, the clinic's chief administrative officer, explored this phenomenon in a commentary they published in Mayo Clinic Proceedings, entitled Pay-for-Performance or Pay for Value? They emphasize that it's patient outcomes — not process — that should be the focus of quality improvement efforts.

"Most of these incentive programs target a mix of process and structural measures with less emphasis on patient satisfaction and overall patient outcomes. Programs have varying payment approaches, but quality bonuses are most common. In this scenario, payers give physicians and medical institutions an annual 'bonus' or percentage for meeting a goal (such as prescribing aspirin at discharge after an acute myocardial infarction) or withhold a small percentage of payment until requirements are met.

Mayo Clinic recently hosted its first National Symposium on Health Care Reform, at which 300 national leaders convened and reached consensus on the direction that reform must take. Two of the key recommendations dealt with value. Participants agreed that the health care system needs to deliver value to all stakeholders and that payment should be based on results of coordinated care delivered over time.

We must move away from pay-for-performance approaches that reward process achievement and move toward paying for value. Patients want health care that is a good value — high-quality health care (good outcomes, safe care, and great service) at a reasonable price."

This value equation would move away from the current emphasis on processes and focus instead on patient outcomes. Improving processes of care is still important, but making sure that the processes result in improved care for patients will result in increased value and increased patient satisfaction.

An example of this is Mayo Clinic's STEMI project: a time-shaving approach to help more patients survive the most serious heart attacks.

The goal: Streamline care so time elapsed from when a patient enters the emergency department door to the moment a tiny balloon opens a blocked artery in the cardiac catheterization laboratory — balloon angioplasty — is 90 minutes or less. Few hospitals (less than 40 percent for non-transferred patients and less than 5 percent for transferred patients) meet this objective. The approach is dubbed door-to-balloon (D2B) time. The American College of Cardiology in collaboration with the American Heart Association and other organizations launched a national campaign to improve D2B times in 2006.

Mayo Clinic began its initiative in 2004, according to Henry Ting, M.D., the Mayo cardiologist who headed the multidisciplinary team effort. In two years, the median D2B time decreased from 92 minutes to 60 minutes for patients who come to Saint Marys Hospital in Rochester, Minn.

This quicker response saves the lives of patients with ST-elevation myocardial infarction (STEMI), a type of heart attack with total blockage of an artery (about 20 percent of all heart attacks). "Every 30-minute delay before opening the artery increases relative mortality by 8 percent," says Dr. Ting. "For these patients, time is muscle damage, time is cell death, and every minute counts."

Dr. Ting's team also focused on improving results regionally. "Even with our efforts here, we weren't helping most of the people in the region," says Dr. Ting. That's because most community hospitals, where patients go first, aren't equipped to perform balloon angioplasties.

The solution was Fast Track for Heart Attack. Mayo Clinic coordinates with 28 regional hospitals within 200 miles. When a patient's electrocardiogram indicates a STEMI, the Fast Track protocol kicks in. The community hospital starts the right medications and activates the Fast Track with a single phone call. The air ambulance transport and preparations for an angioplasty procedure in Rochester are set in motion.

The median D2B time within 200 miles of Mayo Clinic is 108 minutes, compared to 180 minutes nationally. Sixty of the 108 minutes are to transport the patient to Rochester via helicopter.

"STEMIs are one of the true medical emergencies," says Dr. Ting. "By streamlining the care, we've been able to dramatically improve outcomes."