An analysis of clinical process measures for acute healthcare delivery in Appalachia: The Roane Medical Center experience

Objective To survey management of selected emergency healthcare needs in a Tennessee community hospital. Materials and methods In this descriptive report, discharges and associated standard process measures were retrospectively studied for Roane Medical Center (RMC) in Harriman, Tennessee (pop. 6,757). Hospital data were extracted from a nationwide database of short-term acute care hospitals to measure 16 quality performance measures in myocardial infarction (MI), heart failure, and pneumonia during the 14 month interval ending March 2005. The data also permitted comparisons with state and national reference groups. Results Of RMC patients with myocardial infarction (MI), 94% received aspirin on arrival, a figure higher than both state (85%) and national (91%) averages. Assessment of left ventricular dysfunction among heart failure patients was also higher at RMC (98%) than the state (74%) or national (79%) average. For RMC pneumonia patients, 79% received antibiotics within 4 h of admission, which compared favorably with State (76%) and national (75%) average. RMC scored higher on 13 of 16 clinical process measures (p<0.01, sign test analysis, >95% CI) compared to state and national averages. Discussion Although acute health care needs are often met with limited resources in medically underserved regions, RMC performed above state and national average for most process measures assessed in this review. Our data were derived from one facility and the associated findings may not be applicable in other healthcare settings. Further studies are planned to track other parameters and specific clinical outcomes at RMC, as well as to identify specific institutional policies that facilitate attainment of target quality measures.


Introduction
While health care quality in the U.S. has been found to be inconsistent and sometimes inadequate by several investigators [1,2], objective assessments of quality can provide useful information as quality improvement programs are developed and implemented [3]. Some researchers have observed that care for some seriously ill patients has shown surprising and unacceptable interstudy variation even when objective improvements were registered at the end of an assessment period [4][5][6]. As a medically underserved area, Appalachia encounters any economic downturn with special vulnerability. Hospital policymakers in this region are expected to maintain delivery of health services to their communities with resources that are often limited and insufficient. Against this background, this study examined one Appalachian hospital to determine its current performance vis-à-vis selected clinical process measurements and compared these data to comparable measurements across the state and nation.

Study hospital
Roane Medical Center (RMC) is a 109-bed primary care hospital owned and operated by the city of Harriman, Tennessee (population 6,757 [7].

Data source and statistical analysis
This descriptive study was based on national data collected by short-term acute care hospitals and rural, small, remote "critical access" hospitals and reported to the Centers for Medicare and Medicaid Services. RMC was among the reporting hospitals (n = 3558) that voluntarily submitted data in order to receive an incentive payment established by Section 501(b) of the Medicare Prescrip-Proportion of patients with myocardial infarction (n = 8) given angiotensin converting enzyme inhibitor therapy for left ventricular dysfunction within 24 h of hospital admission (%) at Roane Medical Center (RMC)  Proportion of myocardial infarction patients (n = 25) given aspirin at discharge from Roane Medical Center (RMC) Figure 3 Proportion of myocardial infarction patients (n = 25) given aspirin at discharge from Roane Medical Center (RMC). Mean percentages of patients receiving this intervention in Tennessee (TN) and all hospitals (USA) are also shown for comparison.  Proportion of myocardial infarction patients (n = 6) given smoking cessation counseling/advice before discharge from Roane Medical Center (RMC) Figure 6 Proportion of myocardial infarction patients (n = 6) given smoking cessation counseling/advice before discharge from Roane Medical Center (RMC). Mean percentages of patients receiving this intervention in Tennessee (TN) and all hospitals (USA) are also shown for comparison. The HQA data set provides a large quantity of information about U.S. hospitals where data on at least one stable measure (defined as discharge information derived from at least 25 patients) was reported during the study period.
Our retrospective analysis was based on information extracted from this database specific to RMC, derived from administrative data and medical record documents as primary sources maintained at that facility. RMC's performance data were then referenced with state (Tennessee) and Proportion of pneumonia patients (n = 195) receiving pneu-mococcal vaccination before discharge from Roane Medical Center (RMC) Figure 11 Proportion of pneumonia patients (n = 195) receiving pneumococcal vaccination before discharge from Roane Medical Center (RMC). Mean percentages of patients receiving this intervention in Tennessee (TN) and all hospitals (USA) are also shown for comparison. U.S. national average data for comparison using sign test methodology [8].

Results
We found RMC's score on a majority (13/16) of clinical parameters to be above state and U.S. national reference groups. Specifically, the study hospital's performance on utilization of aspirin on arrival and discharge for myocardial infarction was higher than the state and national average. Administration of beta-blockers for myocardial infarction at RMC was also greater compared to both Tennessee and USA average. Heart failure patients underwent assessment of left ventricular function more often at RMC compared to the state and national average, and RMC   pneumonia patients were treated with intravenous antibiotics at a higher rate than state and national averages. An exception to this trend was noted in RMC's performance on angiotensin converting enzyme inhibitor use among heart attack patients. On this process measure only 78% of patients received the intervention compared to 79% and 80%, as state and national average, respectively. For uncertain reasons, the proportion of heart failure patients receiving angiotensin converting enzyme inhibitor was also nominally below standard reference groups (75% vs 76% and 79%, state and national average, respectively). Center-specific data for RMC cardiac patients given thrombolytic medication within 30 min of arrival or those receiving percutaneous coronary interventions within 120 min of arrival could not be compared to reference groups, because these services were not provided at the study hospital. RMC's performance as measured by the HQA initiative for all relevant categories is compared to state and national reference groups in figures 1, 2, 3, 4, 5, 6,7,8,9,10,11,12,13,14,15,16 and Table 1.

Discussion
Appalachia is one of several U.S. regions often identified as medically underserved [9], and its formidable healthcare needs have been described by numerous investigators [10,11]. Against this background, hospitals have confronted the challenge of diminished reimbursement, high expenses, limited staffing and other financial hardships in a variety of ways. An uncertain and difficult economic climate in the region has contributed to closure or consolidation of many small hospitals providing important primary care services to their local communities [12,13].  Several healthcare institutions in Appalachia have adapted to the changing healthcare landscape, even managing to register growth despite a hostile marketplace. One facility that has weathered this storm is Roane Medical Center (RMC), located in Harriman, Tennessee. A study of specific management strategies potentiating the survival and growth of this institution is beyond the scope of the current report. Instead, we focused on objective measurement of RMC's performance with a select group of standardized acute healthcare clinical processes as measured by the Hospital Quality Alliance (HQA). This initiative is the first effort to report data on hospital performance on a national scale [14], and permitted comparison of RMC with reference groups both within Tennessee as well as nationwide.
Research based on HQA data recently found no relationship between clinical performance on these standardized parameters and hospital size [14]. However, these investigators found a small but significant increase in performance among academic, Northeastern or Midwestern nonprofit hospitals. Southern and far Western states, in contrast, tended to do less well on heart care measures [15]. Our research found RMC (a small, non-academic, not-forprofit hospital in the rural South) performed above state and national average on most of these specific clinical parameters. Indeed, the only process measures where RMC performed marginally under state and national average was among pneumonia patients receiving blood cultures, and heart failure/myocardial infarction patients receiving angiotensin converting enzyme inhibitor therapy.
Our analysis was limited by several factors. The clinical parameters covered in this report did not capture data on all hospital encounters, and represent only about 15% of all Medicare admissions [14]. It must be acknowledged that process measures are distinct from patient outcomes, and this investigation assessed only the former. Since RMC is a small facility, the number of patients presenting with certain medical conditions during the study interval was limited and likely introduced some error due to insufficient sampling. Our results describe process measures only at one institution and may not apply to different health care facilities where different policies and practices prevail. We also assumed the data reported represented independent variables, permitting robust comparisons for each process measurement. Additionally, while data collecting and public reporting of healthcare quality measures to the HQA database is an important beginning, our findings suggest that other relevant clinical benchmarks will need to be surveyed going forward. Data gathering should be expanded to include more diseases and conditions to depict a more complete picture of hospital care in rural Appalachia and nationwide. The HQA project presents valuable information for consumers, physicians, and administrators -all of whom have an interest in improving hospital care in the U.S.