Abstract
This study evaluates the designation of center of excellence by insurance payers for hospitals performing percutaneous coronary intervention.
The designation of centers of excellence (COE) hospitals has been proposed as a way of constructing networks that deliver high-quality care and is already affecting physician and hospital choice for some patients.1 Previous studies of COE programs have been limited to surgical procedures and have had mixed results.2 We analyzed the association between patient outcomes and characteristics of hospitals performing percutaneous interventions (PCIs) in New York State (NYS) and COE programs by 3 commercial payers: Institutes of Quality for cardiac medical interventions by Aetna Inc, Centers of Excellence for cardiac catheterization and angioplasty by Cigna, and Blue Distinction Centers for cardiac care by Blue Cross Blue Shield (BCBS).
Methods
We used the NYS PCI reporting system to obtain hospital-level, aggregated, 30-day risk-adjusted mortality and readmission rates after PCI and acute myocardial infarction for all nonfederal hospitals in NYS where PCI was performed in 2015. Other data were obtained through the American Hospital Association survey, NYS Department of Health, and the Hospital Consumer Assessment of Healthcare, Providers and Systems (HCAHPS) survey. COE designations were obtained from publicly accessible provider directories in March 2018 (Box). As the study only utilizes publicly available, deidentified data, it is considered exempt from institutional review board review based on guidelines from the University of Pennsylvania Institutional Review Board.
Box. Summary of Centers of Excellence Program Designation Criteria.
Aetna Institutes of Quality for cardiac medical interventions3: Hospitals need to perform at least 200 PCIs over a 12-month period, have a 30-day risk adjusted mortality rate of ≤1% for patients receiving cardiac catheterization and ≤3% for patients receiving PCI. Additional criteria include availability of certain treatment capabilities, thresholds for cardiovascular mortality and post-procedure complications and readmission rates as well as evaluation of patient satisfaction and participation in quality improvement registries. Hospitals are then assessed for cost efficiency and network access, after which they can be designated an Institute of Quality.
Cigna Centers of Excellence for cardiac catheterization and angioplasty4: Hospitals need to perform at least 100 cardiac catheterizations to be evaluated. A quality index using health care infections, procedural complications, hospital wide readmissions, the Leapfrog Group hospital safety score, and Hospital Consumer Assessment of Healthcare, Providers and Systems rating is calculated. Hospitals are also evaluated for cost-efficiency. A combination of outcomes and cost-efficiency are used for designation as a COE.
Blue Cross Blue Shield Blue Distinction Centers for cardiac care5: Centers need to perform at least 100 PCIs to be eligible. A designated hospital needs to have a 90% lower CI for risk-adjusted mortality rate of 1.7% or lower and 5.4% or lower for risk-adjusted bleeding rate. Criteria regarding appropriate use of PCI are also included. A designated hospital needs to have similar or better than the national average mortality and readmission rates after acute myocardial infarction. Hospitals also need to have certain treatment capabilities, participate in national registries and be accredited by The Joint Commission.
To minimize the statistical instability of clinical outcomes from low-volume hospitals, we used a hierarchical Poisson estimator to shrink estimates toward the overall mean rate.6 We then compared clinical outcomes and hospital characteristics for each COE program between designated and nondesignated hospitals. Data analysis was performed between March 1 and July 31, 2018.Comparisons were conducted using 2-tailed unpaired t tests. P <.05 was considered statistically significant. Data analysis was conducted using SAS, version 9.4 (SAS Institute).
Results
Sixty-two hospitals were included in the analysis. Five hospitals (8%) had a COE designation by Aetna, 9 hospitals (15%) had a COE designation by Cigna, and 17 hospitals (27%) had a COE designation by BCBS (Table). Hospitals with an Aetna COE designation had a significantly higher mean (SD) 30-day risk standardized mortality rate after PCI compared with hospitals without the designation (1.4 [0.9] vs 1.1 [0.9] deaths per 100 cases; P = .002). There were no differences in mortality rates after PCI for the other 2 programs. There were also no differences in 30-day risk standardized readmission rates after PCI or 30-day risk standardized mortality rates after acute myocardial infarction for any of the 3 programs. Hospitals with a BCBS COE designation were more likely than nondesignated hospitals to have a cardiac intensive care unit (17 [100%] vs 31 [69%]) and on-site cardiac surgery (17 [100%] vs 19 [42%]). There were no differences in the proportion of hospitals achieving a high HCAHPS score by COE designation status. A sensitivity analysis excluding emergency PCI showed similar results.
Table. Comparison of Patient Outcomes and Hospital Characteristics by Each COE Designation.
| Variable | Aetna Institutes of Quality | Cigna Centers of Excellence | Blue Distinction Centers | |||
|---|---|---|---|---|---|---|
| COE Designated | Not COE Designated | COE Designated | Not COE Designated | COE Designated | Not COE Designated | |
| Total No. | 5 | 57 | 9 | 53 | 17 | 45 |
| Clinical outcomes | ||||||
| No. of PCI cases (Q1-Q3) | 720.6 (420-910) | 797.05 (282-1056) | 840.4 (302-1041) | 782.5 (280-1056) | 980.8 (703-1056) | 719.1 (187-778) |
| 30-d Risk standardized readmissions rate after PCI (readmissions per 100 cases), mean (SD) | 9.6 (5.2) | 9.5 (5.7) | 9.4 (4.4) | 9.5 (5.8) | 9.1 (7.3) | 9.7 (4.6) |
| 30-d Risk standardized mortality rate after PCI (deaths per 100 cases), mean (SD) | 1.4 (0.9)a | 1.1 (0.9)a | 1.2 (1.1) | 1.2 (1.0) | 1.1 (1.1) | 1.2 (1.0) |
| No. of acute myocardial infarction cases (Q1-Q3) | 293.8 (239-356) | 291.4 (186.5-359) | 346 (209-365) | 282.1 (173.5-354.5) | 364.3 (254-441)b | 265.7 (162-344)b |
| 30-d Risk standardized mortality rate after acute myocardial infarction (deaths per 100 cases), mean (SD) | 8.3 (1.3) | 8.4 (1.4) | 8.2 (1.8) | 8.4 (1.3) | 8.4 (1.8) | 8.4 (1.2) |
| Hospital characteristics | ||||||
| New York metropolitan area, No. (%) | 3 (60) | 37 (65) | 9 (100)b | 0b | 9 (53) | 31 (69) |
| Total hospital inpatient beds, mean (SD) | 465.4 (262.0) | 484.7 (223.6) | 520.3 (225.6) | 476.8 (225.9) | 559.3 (235.1) | 454.3 (216.1) |
| Cardiac intensive care unit, No. (%) | 4 (80) | 44 (77) | 8 (89) | 40 (75) | 17 (100)b | 31 (69)b |
| Cardiac surgery available, No. (%) | 3 (60) | 33 (58) | 4 (44) | 32 (60) | 17 (100)a | 19 (42)a |
| Cardiac rehabilitation services available, No. (%) | 3 (60) | 40 (70) | 6 (67) | 37 (70) | 14 (82) | 29 (64) |
| The Joint Commission accreditation, No. (%) | 4 (80) | 47 (8) | 9 (100) | 42 (79) | 14 (8) | 37 (8) |
| Major teaching hospital, No. (%)c | 2 (40) | 20 (35) | 3 (33) | 19 (36) | 10 (59)b | 12 (27)b |
| Safety net hospital, No. (%) | 4 (80) | 44 (77) | 4 (44)b | 44 (83)b | 12 (71) | 36 (80) |
| Medicaid-Medicare, dual-eligible, uninsured patients, mean (SD) | 39.3 (8.2) | 43.3 (17.5) | 42.6 (26.8) | 43.1 (15.0) | 38.3 (14.1) | 44.8 (17.7) |
| HCAHPS rating of 3 or 4, mean (SD)d | 2 (40) | 22 (39) | 3 (33) | 21 (40) | 5 (29) | 19 (42) |
Abbreviations: COE, center of excellence; HCAHPS, Hospital Consumer Assessment of Healthcare, Providers and Systems; Q1, first quartile; Q3, third quartile.
P < .01 between COE designated and nondesignated hospitals.
P < .05 between COE designated and nondesignated hospitals.
Major teaching hospital status defined by membership of the Council of Teaching Hospitals and Health Systems.
Overall HCAHPS survey summary rating.
Discussion
We found a lack of correlation between COE designation and lower mortality or readmission rates. For 2 programs (BCBS and Cigna), there were no significant differences between COE and non-COE hospitals in mortality or readmission rates after PCI or acute myocardial infarction. However, for hospitals with an Aetna COE designation, the mean 30-day risk standardized mortality rate after PCI was modestly, but statistically significantly, higher than for hospitals without the designation. Possible reasons include eligibility criteria that do not discriminate between hospitals based on performance. For example, the mortality thresholds used for Aetna and BCBS programs (Box) exceed the mean 30-day, risk-standardized mortality rate after PCI in NYS of 1.2 (1.0) deaths per 100 cases. The Aetna program requires participation in the HCAHPS survey alone, rather than achieving a threshold rating for patient satisfaction.
Our study is limited by the small number of hospitals in each program. Hospitals could also differ in other important outcomes that were not measured by our study. Given the insufficient discrimination provided by these programs, the current system of COE designation may allow for assignment based largely on cost and other nonclinical or patient-related factors. Our findings call into question the usefulness of current COE designations; work is needed to improve criteria that clearly identify hospitals that outperform their peers.
References
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