Do Cardiac Centers of Excellence Really Excel?
A look at 30-day outcomes
If I needed a cardiac procedure, I might look for a hospital designated as a cardiac “center of excellence” (COE) by my insurer. I might assume that the hospital delivers higher quality care and achieves better outcomes than other hospitals. But that assumption might be wrong, according to a new study by LDI Associate Fellow Sameed Khatana and colleagues in JAMA Internal Medicine.
Khatana et al. analyzed publicly reported outcomes (30-day risk-adjusted mortality and readmission rates) from percutaneous coronary interventions (PCIs, or angioplasties) and acute myocardial infarction from 62 hospitals in New York State. They compared hospitals with and without a COE designation for cardiac care from one of three commercial payers: Aetna, Cigna, and Blue Cross Blue Shield. They found no correlation between COE designation and lower mortality rates after myocardial infarction. For PCI, they found no differences in mortality or readmissions by COE status for Cigna and BCBS, but a modestly higher mortality rate after PCI in hospitals with an Aetna COE designation.
To understand their findings, we can look to the criteria used for the designation [box]. For example, the authors note that the mortality thresholds used by Aetna and BCBS exceed the average 30-day risk-adjusted mortality rate after PCI in New York State; and that the Aetna program simply requires participation in patient satisfaction surveys, rather than a threshold rating. Given that the criteria often include achieving cost efficiency, the COE may say more about how much the hospital spends on care than about the outcomes it achieves.
Although the study is a small one, it calls into question the usefulness of current COE designations. Khatana and colleagues conclude:
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…work is needed to improve criteria that clearly identify hospitals that outperform their peers.
The study, “Centers of Excellence Designations, Clinical Outcomes, and Characteristics of Hospitals Performing Percutaneous Coronary Interventions,” was published online in JAMA Internal Medicine on May 20, 2019. Authors include LDI fellows Sameed Khatana, Ashwin Nathan, Elias Dayoub, Jay Giri, and Peter Groeneveld, from Penn Medicine’s Cardiovascular Outcomes, Quality, and Evaluative Research (CAVOQER) Center.