The CFA Perspective

The Re-emergence of the Center Of Excellence

Posted by Peter Rastello

4/4/11 4:19 PM

Will the passage of the Patient Protection and Affordable Care Act (PPACA) in 2010 usher in a renewed emphasis on hospital Centers of Excellence (COE)?  Did the Center of Excellence concept ever really go away?  Whatever you call it, and most importantly, however you define it, the COE remains a logical concept for organizing, staffing, marketing and focusing resources on a relatively homogenous patient population of great importance to the typical hospital.  This has been particularly true with comprehensive cardiovascular services, as they comprise a highly visible clinical service frequently contributing significant revenue to the hospital or health system.  Successful CV programs require focused management, significant and regular capital investment in expensive technology, ongoing clinical development and a large and diverse specialty medical staff.  Are these programs comprehensive CV service lines or CV Centers of Excellence?  CFA believes that the most successful programs are nearly indistinguishable.


One way to interpret the intended consequences of the PPACA is the push towards a number of new payment incentives that require a closer working relationship between physicians and hospitals.  These include accountable care organizations (ACOs), pay-for-performance-type programs, payment bundling (hospital and physicians), and several other initiatives.  If hospitals need to work more closely with their physicians towards achieving common objectives, then what better way to organize this effort than around a specific service line, or Center of Excellence?  With healthcare reform promoting better health outcomes at lower cost, it makes sense that hospitals look at the best way to approach their individual strategic and operational response to reform. 


COEs are a logical place to start.  Currently, while cardiovascular specialists focus their attention on the service line that supports their work, their level of engagement varies.  COE development can be promoted by enhancing physician/hospital integration.  Specialty physicians can be expected to work more closely within their respective hospital service lines to promote increasing value to patients and payers when they are incentivized to do so.


Focus on COE development will parallel the needs of the developing PPACA-sponsored efforts.  Physician-hospital alignment and comprehensive integration can create the mechanism for goal congruence and appropriate incentivization towards these goals.  Alignment/integration strategies must focus on how these strategies will successfully support the goals and objectives of the service line.


Beyond fostering closer integration and alignment with the CV medical staff to better respond to emerging requirements of the PPACA, CFA believes that eventually governmental payers will contractually steer patients to the higher quality and lower cost providers (as many private payers/managed care plans do today).  This eventuality will be driven by the necessity for Medicare and Medicaid to achieve substantial cost savings in the face of increasing demand for services by our aging population.  Preparing and positioning to respond to such a heightened competitive arena will likely drive CV COEs to re-double their program development and management efforts to new levels.  This is what CFA calls a Performance-Based Center of Excellence.


We will leave the discussion of what is required to turn a service line into a “Performance-Based” Center of Excellence for a future article.


CFA invites your thoughts, comments and questions.

Topics: Clinical Performance Improvement, Cardiovascular Hospital Services Optimization

SYNTAX Trial – Is CABG Underused?

Posted by Peter Rastello

10/6/10 7:10 PM

We were recently discussing our years in the field of cardiovascular medicine and one of my colleagues vividly remembered the day our hospital performed its first percutaneous transluminal coronary angioplasty (PTCA) more than 30 years ago.  Our cardiovascular program was very early adopting the technology which required the hospital to send two of its best soon-to-be “interventional” cardiologists to Switzerland to learn the procedure directly from Dr. Andreas Gruentzig himself.  A new day dawned and the development and inevitable ascent of percutaneous coronary intervention (PCI) began.  With the rapid dissemination of this new technology, and the eventual addition of coronary drug-eluting stent technology, cardiologists had a new, clinically effective and cost effective tool that obviated at least some patients from having to undergo coronary artery bypass graft (CABG) surgery.  As it turned out, a lot of patients have avoided CABG since then!  According to the National Center for Health Statistics, PCI increased from about 561,000 patients in 2000 to about 1,313,000 patients in 2006 (up 134%).  CABG began its concomitant decline in volume from a high of about 607,000 patients in 2000 to a low of about 448,000 patients in 2006 (down 26%).  Not-so-gradually, a less-invasive, less expensive and safer procedure was able to eliminate a large number of more costly surgical procedures with considerably higher risks and recovery implications.  A good thing, right?


Maybe not.  The SYNTAX Trial (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) the first large trial to compare stenting and CABG directly, first reported in early 2009, has continued to stir the controversy.  The trial randomized 1,800 patients (in Europe and the U.S.) with severe CAD to either CABG or drug-eluting stents, and followed them for twelve months thereafter.  On September 12, 2010 in Geneva, additional results were reported.  The researchers conclude that tens or even hundreds of thousands of Americans are having coronary artery angioplasty and stenting every year when they should be having CABG, and the result is an extra 5,000 or more deaths annually.  The trial randomized patients with severe CAD -- triple-vessel or left main disease.  This group has remained nearly the only subset of patients that cardiologists feel compelled to refer for CABG surgery.  It has been suggested that cardiologists have long been desirous of trial results that would show that stents are just as good as CABG even in these patients.


SYNTAX seems to prove otherwise. Three years after the procedure, those that received a stent procedure were 28% more likely to suffer a major event such as a heart attack or stroke, and 46% more likely to require a repeat revascularization.  They were also 22% more likely to have a mortal event.  It seems that, for the most severe disease, surgery has a real patient advantage.   For patients with mild disease, the two procedures offer equivalent results.  But the differences were much more dramatic for patients with more severe CAD.  Approximately 50% of all patients undergoing angioplasty in the U.S. have more severe disease.  Hence, the researchers conclusion that CABG is underutilized for patients in this category.


While surgeons have touted these results, some cardiologists continue to believe that some patients with severe CAD should still be considered candidates for stenting despite the results of the trial.  They argue that some of the “endpoint events” in the study, such as the rate of stroke (lower in stents than in CABG) are more important than others and work in coronary stenting’s favor.  To this end, the SYNTAX investigators are working to develop a “SYNTAX score” that would help physicians determine which patients would benefit the most from which procedure.  It seems inevitable that additional clarification will be produced; guidelines, protocols (and perhaps even governmental and/or insurance company dictates) will be produced to reflect the SYNTAX conclusion.  Cardiac surgeons may be happy, but how far will these results go in settling this issue with cardiologists and their patients (let’s not forget the need for a well informed patient in all this), and how will this impact CABG volumes over the next few years?  Despite SYNTAX, the struggle between competing procedures and competing specialists will surely continue.  Well designed research should clarify and enlighten.  Unfortunately, no matter how good the research and compelling the findings, sometimes enlightenment is often a difficult end point to achieve.


CFA invites your thoughts and comments.

Topics: Clinical Performance Improvement, PCI, CABG

Public Release of Online CABG Report Cards

Posted by Peter Rastello

10/1/10 3:04 PM

On September 7, 2010, Consumer’s Union (publisher of Consumer Reports) reported the results of coronary-artery bypass graft (CABG) procedures at 221 surgery programs (about 20% of U.S. programs).  Matched with a Perspective article in the September 9, 2010 issue of the New England Journal of Medicine online, which described this voluntary reporting as a “watershed event;” thus having enormous implications for hospital CV programs.  The data derive from the Society of Thoracic Surgeons (STS) database used by 90% (1,100) U.S. cardiac surgery programs.  Each volunteering program is now rated one, two or three stars based on an analysis of eleven performance measures endorsed by the National Quality Forum (see the article for a complete listing of outcome measures – they should be familiar to everyone).  The ratings depend upon whether the risk-adjusted outcomes in a program fall below, are equal to, or exceed the average performance range. 


STS data has historically been closely held by its participating hospitals and surgeons.  This effort on their part to make it transparent will be widely debated.  The ratings have their shortcomings.  They are voluntary, and typically only those with good ratings have released the information (50 programs that received three stars released data while only 5 with one star released their information).  This effort begs real questions of how valid such rating systems are in helping consumers choose between competing programs, and whether voluntary or mandatory systems are optimal.  However, the mounting consumer (and governmental) pressure for transparency was instrumental in bringing this rating system to completion.  The oft heard complaint of physicians, that such data is not valid, is countered with the voluntary release of data from participating physicians themselves under the imprimatur of their own professional society (the STS) which has been highly rigorous in testing its validity.


The authors conclude with the following comments:


  • Regardless of the approach taken to transparency (voluntary or mandatory), public reporting will increasingly be a fact of life for physicians.
  • The approach taken by the STS can be applied to other initiatives aimed at bringing performance data derived from clinical sources to the public (and thereby reducing the time and expense involved).  Other professional groups (e.g., vascular surgeons) are surely next.
  • This experience may contain lessons for the Center for Medicare and Medicaid Studies as it prepares to handle the sea of new clinical data mandated under programs such as the Physician Quality Reporting Initiative and the “meaningful use” requirements for electronic health records.


CFA strongly concurs with the first bullet – public reporting is here and will increasingly be a part of every hospital and cardiovascular physician groups’ daily lives.  CFA’s earlier blog posting – The Best Measure of Outcome is Outcome – published on our website Thursday, March 18, offered recommendations for dealing with Volume/Outcome issues that are generally applicable to the CABG data as well.  


CFA refers you to for the Perspective article:  Public Release of Clinical Outcomes Data – Online CABG Report Card – which is a free download.  Additionally, the 50 Top Rated Surgical Groups in the U.S. was published in Consumer Reports, October 2010 issue. The complete ratings are available at (although the actual scoring can be reviewed by website subscribers only).


What do you think?  As always, CFA invites your comments, suggestions and questions.

Topics: Clinical Performance Improvement

The Transradial Approach to PCI – A “Win-Win” for Everybody?

Posted by Peter Rastello

3/31/10 7:30 AM

When was the last time you came across a simple and straightforward change in clinical technique that typically results in better clinical outcomes, fewer complications, higher patient satisfaction, and lower cost per procedure?  While that has occasionally happened in the cardiovascular field, the increasing trend for substitution of the transradial (through the wrist) for the transfemoral (through the groin) approach for PCI, seems to be a real "win-win" for everyone involved.

 Traditionally, guidewires and catheters for PCI are inserted through the femoral artery.  Bleeding or vascular complications occur about 2% of the time.  Patients are recovered lying flat and immobile for 4-6 hours to prevent bleeding, which has also been helped by the advent of vascular closure devices.  The patient is more comfortable, dangerous bleeds are reduced, but vascular complications still exist.  Enter the transradial approach in the late 1980's.  Outside of the U.S., about 40-50% of all PCI's are done transradially.  In the U.S., that number currently is in the low single digits and only a small percentage of U.S. interventional cardiologists have been trained to use this approach.

 The advantages of the transradial over transfemoral approach are significant and include:

  • The initial needle puncture is simple and straightforward
  • Not impacted by a patient with peripheral vascular disease, obesity or female gender
  • No need to recover the patient lying flat and immobile; patients are recovered sitting up and can leave the cath lab almost immediately post-procedure; this allows (theoretically) the patient to forgo spending an overnight stay in the hospital
  • Because no vascular closure device is required, a significant cost is eliminated
  • Less bleeding and other complications, significantly decreasing the risk of mortality
  • If present, bleeding or other complications are readily identified and easy to address
  • Overall case cost is decreased by obviating the use of vascular closure devices
  • It is safer, more convenient, and more comfortable for the patient

 There are several reasons the approach has not been used more frequently, including:

  • Lack of trained cardiologists
  • Lack of financial incentives due to the existing reimbursement structure
  • Lack of a marketing campaign by device manufacturers (who have concentrated their efforts outside the U.S.)
  • Lack of patient demand because the approach has not been widely publicized
  • An impression that the learning curve is too steep and learning inertia on the part of busy interventional cardiologists
  • Lack of recognition and inclusion in practice guidelines or recommended practices by professional societies

 As with any procedure, there are certain contraindications and potential complications.  Additionally, physicians need to be trained in the procedure by those with solid experience.  Like all new procedures, there is a learning curve.  Despite these factors, the transradial approach is gaining momentum, fostered by recent study results and an increasing recognition by influential physicians that this approach has real benefit.  CV services management staff should fully evaluate this approach, seek out physician champions and put together an implementation plan to successfully integrate this technology into their program.  This can be a perfect hospital and physician performance improvement project or targeted metric as part of a physician/hospital alignment effort.  It's not very often that a modest clinical change can simultaneously improve clinical outcomes, reduce complication rates, increase patient satisfaction, and lower procedure costs and be a "win-win" for all involved!

 For further information, CFA suggests you review the article, Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention:  A Report from the National Cardiovascular Data Registry, published in the November 2009 Journal of the American College of Cardiology - Cardiac Interventions.

Topics: Heart Hospital Services Optimization, Clinical Performance Improvement, Cardiovascular Physician-Hospital Alignment, Clinical Programs & Services

Clinical Performance Improvement: “The Best Measure of Outcome is Outcome”

Posted by Peter Rastello

3/18/10 1:13 PM

Over the long consulting careers of CFA's Principals, the relationship between cardiovascular procedural volume and quality outcomes has continually merited examination.  Multiple studies have addressed the issue for a wide range of cardiovascular procedures.  It is intuitive-isn't it?-that higher volume cardiovascular programs produce better outcomes, and vice versa?

Researchers, professional societies (through evidence-based practices), payers and the media have all addressed the issue, in some cases setting guidelines and standards for minimum volumes at both the program and physician operator level.  In certain states, falling below a minimum volume standard can trigger a clinical audit and could result in program decertification.  Unfortunately, we all know that "volume equals quality" just isn't that simple-it is complex and heavily nuanced.

A recent example of research into this issue was published in the Journal of the American Medical Association in November 2009.  The article examined the association of hospital primary angioplasty volume with quality and outcome.  One of its authors, Dr. Deepak L. Bhatt of the Cleveland Clinic, concluded that the mortality from small, medium and large volume providers does not differ considerably. Other markers of quality were also studied, such as door-to-balloon times and length of stay.  He further concluded that,

"As common sense would suggest, certainly there is a level where volume does matter, but in the contemporary era, that threshold may vary.  The best measure of outcome is outcome."    

Dr. Bhatt's conclusion is surprising simple, yet profound:  the best measure of outcome is outcome.  In this era of pay for performance, bundling payments, rewarding specific levels of outcome metrics, demand for increasingly transparent results and heightened public expectations, hospitals need to pay strict attention to Dr. Bhatt's simple conclusion and make it work for their program.

CFA recommends that hospitals (and individual physician operators) whose CV service line volume of a key procedure falls below generally accepted minimum volume indicators take the following actions:

  • Acknowledge that for some individuals and organizations, volumes and outcomes will always be linked.
  • Establish specific and detailed outcome metrics for your program and insure that all applicable quality outcomes for the procedure meet or exceed generally accepted standards.
  • If there are deficiencies, internally acknowledge them and work vigorously, in a coordinated manner, to address and improve performance to initially attain acceptable and then higher levels of performance.
  • Enlist the aid of your physician staff in understanding the problem, setting acceptable levels of performance and addressing the underlying issues.
  • Take the necessary strategic planning steps to understand the underlying reasons for volume changes and explore what must occur to raise volume above applicable standards. Has volume declined in the overall market? Is there a trend in just one clinical segment of the market? Has a competitor moved market share? Has a key technology changed? Is this a physician supply issue? Remember however, that successfully raising volume does not obviate the need to aggressively manage outcome metrics. Raising volume in the presence of a significant underlying issue could actually negatively impact a key outcome metric.
  • Be prepared to defend your volume and related outcomes against any assault-from the media, your competitors, regulators or other interest groups. Have your data ready and your communication plan developed well in advance. In this case, the best offense is a good defense.
  • If all else fails, carefully consider any programmatic consolidation opportunity that may arise within the service line. Obviously not for everyone, but for a select few, consolidation may be the optimal solution.

For further information, CFA refers you to Association of Hospital Primary Angioplasty Volume in ST-Segment Elevation Myocardial Infarction with Quality and Outcomes, published in JAMA, November 25, 2009; 302(20); 2207-2213. (

Topics: Heart Hospital Services Optimization, Clinical Performance Improvement, Cardiovascular Hospital Services Optimization