All health care is local

Atul Gawande’s compelling article for the New Yorker, “The Cost Conundrum,” discussed variations in health care system performance throughout the country. Such variations are apparently related to differences in medical and hospital practices. Dr. Gawande’s point: using relatively more health care in one part of the country does not mean patients are necessarily receiving better care or experiencing better outcomes. In fact, the reverse may be true.

That’s good news if the health care legislation now being debated in Washington finds ways to improve care and costs in inefficient medical geographies without penalizing areas where medical care has already achieved greater efficiency and effectiveness.

For over two decades the Syracuse hospitals have worked together through the Hospital Executive Council (HEC) to help improve acute care services. That’s a message the CEOs of Syracuse hospitals delivered last week when we met with Rep. Dan Maffei to explain our relatively better performance within New York State.

We showed Congressman Maffei the Syracuse area's lower discharge rate. A low discharge rate means fewer patients are being cared for in hospitals – the most expensive place for care – in proportion to the overall population. The point is made by comparing the discharge rates per 1,000 population among New York metropolitan areas, based on 2007 data. [1]

You can see that Syracuse is among the more efficient medical markets, about one-fifth more efficient than top utilizing areas, New York City and Utica.

Discharged Patients per 1,000
Oneida County (Utica) – 113.3
New York City (New York) – 101.8
Erie County (Buffalo) – 99.3
Albany County (Albany) – 90.7
Monroe County (Rochester) – 82.5
Onondaga County (Syracuse) – 84.2

The Syracuse area has also done a better job in managing the time patients remain in hospitals. The mean length of stay among Syracuse hospitals -- at 5.37 days -- is about one-tenth below the highest area (New York).

Mean Length of Stay
New York City (New York) – 5.93
Erie County (Buffalo) – 5.68
Monroe County (Rochester) – 5.62
Albany County (Albany) – 5.56
Oneida County (Utica) – 5.42
Onondaga County (Syracuse) – 5.37

The combination of lower per capita utilization and lower lengths of stay gives Syracuse hospitals fewer patient days per 1,000 population. This means that aggregate hospital capacity is more efficiently utilized. By “aggregate capacity” I mean the productive resources acute care hospitals employ, such as the patient rooms, medical equipment, professional and support staffing, and medical-surgical supplies.

Compared with areas of higher capacity utilization, Syracuse hospitals are about one-quarter more efficient.

Patient Days per 1,000 Population
Oneida County (Utica) – 614.2
New York City (New York) – 603.7
Erie County (Buffalo) – 563.9
Albany County (Albany) – 504.4
Monroe County (Rochester) – 463.7
Onondaga County (Syracuse) – 452.4

Some may question with shorter hospital stays are Syracuse patients being readmitted more frequently? The answer is no.

Through the HEC, the hospitals are participating in a demonstration of new software (developed by the 3M Corporation) that examines all patient data to determine readmission rates for the portion of the patient population that is at risk of being readmitted. [2] Based on 2008 data, the readmission rate for Syracuse hospitals is one-quarter below the expected rate.

Former Speaker of the House Thomas “Tip” O’Neill famously said, “All politics is local.”

As it happens, so is health care.

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[1] Prepared by the Hospital Executive Council, the data include medical, surgical, pediatric, and neonatal discharges. Source material: the New York Statewide Planning and Research Cooperative System (SPARCS) for resident discharged patients and the New York Statistical Information System for the state population.

[2] According to the HEC, potentially preventable readmission (PPR) software from the 3M Corporation examines the numbers of patients with at least one return to hospitalization within 30 days for non-elective reasons. The readmissions are identified when they are clinically related to the initial hospital admission. The data are statistically adjusted for differences in severity among hospitals and regions.

Diversion hours were 39% lower last year

Last year diversion hours at Community General's emergency department (ED) fell from an average of 6.9 hours per day (2007) to 4.4 hours (2008). That’s a reduction of 39%. And things were better during the fourth quarter when Community's diversion hours dropped from an average 8.5 hours a day to 2.2 hours, a 74% decline.

Syracuse hospitals generally did a better job last year of providing access to emergency care. Collectively the four non-federal hospitals reduced diversion hours by 10% in 2008 -- and by 57% in the fourth quarter.

When a hospital is “on diversion,” its emergency department asks ambulances to “divert” emergency patients elsewhere. If all Syracuse hospitals happen to be on diversion simultaneously, then the emergency medical system (EMS) directs ambulances to each hospital in sequence.

Diversion occurs when there is an imbalance between patient demand and hospital capacity. If too many patients seek care for the size of an ED or its staff, a hospital may request diversion until a balance is restored. Sometimes an internal event (for example, water line break) may prompt diversion status.

When hospitals are on diversion, a patient seeking care at one hospital may end up at another, at a place where her doctors are not available and where her medical records are not at hand. That’s why the American College of Emergency Physicians, among others, has guidelines for ambulance diversion.

Even when on diversion, however, a hospital's ED is not actually closed. Every emergency department will accept a patient who presents herself for emergency care at any time. A patient has the right to insist that an ambulance go to the hospital of her choice, irrespective of diversion status.

Through the Hospital Executive Council (HEC), a planning agency, Syracuse hospitals have worked together to understand and reduce diversion hours. Funded by the hospitals, the HEC shares data, conducts analyses, and helps support cooperative initiatives to improve health care efficiency and quality.

Diversion is not only about emergency department issues. Does a patient remain in the ED longer than necessary while waiting for a hospital bed to become available? Is a hospital’s length of stay extended because of delays in tests or test reports, because of the time it takes to prepare a room for the next patient, or because patients cannot readily be transferred to nursing homes? Diversion is an indicator of the flow and efficiency of, not just a hospital, but of the health care system within a community.

Here’s an interesting note: last month Massachusetts ordered hospitals to stop diversion, except in specific cases. Syracuse hospitals have reduced, but not eliminated, diversion hours, and we’ve done so voluntarily and cooperatively.

It will be interesting to see the experience of Massachusetts with its regulatory approach.

A trusted collaborator

I've heard this from state officials, as well as from other hospital CEOs throughout the state: Syracuse hospitals are unique in that we communicate with one another and we actually work together on cooperative projects.

I was reminded of this last week at the annual meeting of Community General Hospital. One of the annual reports is the status of organizations in which Community is a partner with other health care providers. For example, Community is a partner with Crouse Hospital and St. Joseph’s Hospital Health Center in the Laboratory Alliance of CNY, LLC, Liverpool, NY.

Founded in 1997, the Lab Alliance provides clinical laboratory services to its member hospitals, as well as to physicians’ offices, nursing homes, and other hospitals. With more than 400 employees, last year the Lab Alliance performed 8.1 million tests. It is accredited by the Joint Commission, and it also performs device trials for the manufacturers of laboratory equipment.

Another area where Syracuse hospitals work together is the Plaza Corporation, which has Community, Crouse and St. Joseph’s as members. Plaza is the parent corporation for the 160-bed Iroquois Nursing Home in Jamesville, NY. With Loretto, Plaza is also the sponsor of Rosewood Heights Nursing Home, a 242-bed facility in Syracuse, NY. Combined, Iroquois and Rosewood account for about 14% of the total nursing home capacity in Onondaga County.

EPC, LLC (known as the Endoscopy Procedure Center) is an organization formed in 2005 by Community General Hospital with two medical practices, Associated Gastroenterologists of CNY and Colon Rectal Surgeons of CNY. Licensed as an ambulatory procedure center, EPC provides specialized endoscopy services for patients. It is accredited by the Accreditation Association for Ambulatory Health Care.

Community is also a member in the Hospital Executive Council (HEC), which dates from 1979 and involves Crouse, St. Joseph’s and University Hospitals. The HEC was actually the planning vehicle that helped form the Laboratory Alliance, and it provided the focus for bringing the hospitals together in the Plaza Corporation about two decades ago.

Under the leadership of Ron Lagoe, PhD, the HEC provides data collection, information analyses, and information exchange among its members. It distributes daily reports on Syracuse hospital services, as well as the function of emergency departments in the city. The HEC serves as the hospitals' liaison with the area’s long term care industry, and it is a resource for medical staff credentialing.

The HEC operates multi-year projects that have helped the Syracuse hospitals achieve lengths of stay that are the lowest in New York State, as well as utilization rates that are among the lowest. The HEC is a focus for information and projects that help improve hospital quality and the more effective use of community resources. Ron Lagoe has contributed to the health care literature, using his Syracuse research to publish journal articles on subjects such as provider cooperation, length of stay management, information exchange, hospital-nursing home coordination, and many more.

Part of Community General Hospital's vision is to serve as “a trusted collaborator with those who share its mission.” Through the HEC and the other organizations, we help achieve that goal.