Three days before the biggest operation of his life, 70-year-old Gene Louderback spotted a reassuring story in his local paper. It said heart patients at Richmond's CJW Medical Center had an excellent chance for survival. That was comforting news since Louderback was scheduled for a double bypass there. His father died 30 years ago during bypass surgery. Louderback's own operation, though, was a success. "We could not have been more pleased by how we were treated," he says.

Back when Louderback's father underwent surgery, statistics weren't available that could predict outcomes for heart procedures at specific hospitals. Today, gathering just such data is a growing trend. National database organizations are compiling outcome information into computerized data banks that can be easily accessed by consumers. That's good news not just for second-generation heart patients like Louderback, but for millions of other Americans.

Cardiovascular disease is the number one killer in the United States, claiming nearly one million lives per year. It's one of the most costly diseases as well. Health care costs for cardiovascular disease and sufferers of strokes will total an estimated $329 billion this year, according to the American Heart Association. Since it's primarily a disease of people aged 65 and older, the numbers are likely to grow as baby boomers mature into senior citizens.

The study that reassured Louderback was produced by Richmond-based Virginia Health Information (VHI), which has been collecting health data for the state since 1994. In creating a new state-supported database for cardiac care, VHI compared the actual number of cardiac deaths at Virginia hospitals to an "expected" death total for each hospital, which it established using a range of criteria including diagnoses, procedures and age. Overall, the news is good: Most hospitals performed as expected.

Still, despite the stellar reputations of several of Virginia's heart hospitals, only one - Sentara Norfolk General - earned top marks in the study's three categories: medical (non-surgical) cardiology, invasive cardiology (such as balloon angioplasty) and open-heart surgery. (Just 20 of the state's 82 hospitals did enough open-heart surgeries in 2000 to be included in the later category.)

So what do the results mean? Are reputations of top hospitals inflated? Not necessarily, says Ramesh K. Shukla, a health administration professor at Virginia Commonwealth University who led the study. While there could be real problems at a particular hospital, Shukla says worse-than-expected results may stem from poor documentation. The raw data comes from the medical treatment codes in hospital billing records. The study's complicated formula took into account which hospitals treated patients with complications such as hypertension - as long as the hospital's documents recorded those conditions. While better data collection might improve a hospital's score by up to 10 percent, Shukla says, "We don't want hospitals to hide behind the documentation [issue]. We hope they are sensitized to a need for quality improvements."

That's been the case at Riverside Regional Medical Center in Newport News. The hospital has known since 1999 that its cardiac care needed improvement, so the VHI report wasn't a surprise. "We would have been more reactive if we hadn't already made an effort to grab the bull by the horns," says Dr. Rudolph Freeman, a clinical psychiatrist who took over as the hospital's director of quality review in 1998. Riverside now has a cardiac task force made up of doctors, nurses, case managers and administrators who meet every two weeks to pinpoint problem areas. Previously, doctors, nurses and others in the cardiac unit didn't coordinate quality-improvement efforts. Dr. Freeman says the hospital's data from 2001 shows it has made "a significant improvement in reducing mortality," but he declined to be specific.

Among top hospitals getting a bit of a black eye in the VHI report was Henrico Doctors' Hospital, which showed a greater-than-expected mortality rate in medical cardiology. The hospital was listed as one of the top 100 heart hospitals in the nation by Solucient, a national database that provides US News & World Report with its Top 100 hospitals listing. Steve Tarkington, administrator for critical care services at Henrico Doctors,' points out that "We're treating sicker patients. We see a high proportion of heart failure patients referred here from all over the state." That fact is confirmed by VHI data - Henrico Doctors has a 5.5 percent expected mortality among medical cardiology patients, the highest of Richmond area hospitals. Both of the state's university teaching hospitals, MCV Hospital at Virginia Commonwealth University in Richmond and Charlottesville's University of Virginia Medical Center, had greater than expected mortality rates for patients undergoing open-heart surgery at 2.4 percent and 2.9 percent respectively.

Changes in how patients are classified would help bring that percentage down, says Tarkington. The hospital plans to start admitting terminally ill patients as hospice rather than cardiac patients, says Courtney Cosby, director of quality management. Typically, cardiology patients hadn't been referred to hospice, so those deaths - even though they were anticipated - count in the cardiac outcomes data.

Tarkington doesn't like the VHI data and says it's not just because his hospital didn't make the highest grades. The VHI data simply "is not a good representation. It was shocking that hospitals like Inova Fairfax Hospital, Carilion Roanoke Memorial and University of Virginia Medical Center didn't have higher numbers. I wouldn't hesitate to go to any of those programs," he says. Tarkington and others look to other outcomes databases, which look not only at deaths, but costs of services, post-operative complication rates and length of stay. As Roanoke cardiologist Dr. Paul Frantz says, "There are a lot of data sources and VHI's is the lowest level in the sense that they're taking publicly available information and assimilating it."

Still, unlike other outcomes studies which are national in scope, VHI's study may be the only current statewide effort anywhere in the country. The American College of Cardiology and the Society of Thoracic Surgery both have highly regarded databases, and several Virginia hospitals point out that they fare better in those studies than they did with VHI. These databases, though, aren't for consumers. To get information about specific hospitals, consumers can consult Web sites such as the Evanston, Ill.-based Solucient.com, and Denver-based Healthgrades.com.

Virginia does have another home-grown effort: the Virginia Cardiac Surgery Initiative. The private data base is available only to hospitals performing open-heart surgeries. It began four years ago when such hospitals decided to share proprietary information. Four times a year each hospital gets data showing how it performed compared to other open-heart programs in the state. However, the data isn't identified by hospital name. For the past two years, the data has examined hospital outcomes, but later this year, it will begin reflecting cost of services. In another year, hospitals can start looking at how patients do once they're sent home. "Organizations that do a lower volume can be just as high quality, if not higher, because of best-practice sharing," says Jackie Luchsinger of the Milwaukee-based GE Medical Systems, the firm hired to prepare the reports.

Whether hospitals fared better or worse than they hoped in the VHI report, they all say that quality improvements keep coming. "We may be doing a good job today, but that doesn't guarantee we achieve the same results next time," says Dr. Ron Stine, a Norfolk cardiologist and medical director for the hospital's cardiology program. Cardiology services and surgery keep improving, so "we may be measuring something today that may not be relevant two years down the road."
Indeed, several Virginia hospitals are leaders in the newest small-incision heart surgeries. Carilion Roanoke Memorial Hospital is one of just 10 national centers included in a robotic-surgery study. During this procedure, cardiac surgeon Dr. Paul Frantz says tiny robotic hands are inserted through an incision less than a quarter of an inch long. The surgeon controls the robotic arms from a console while two cameras magnify each step of the surgery on screen. Small-incision surgeries have already reduced post-operative hospital time to three or four days, down from the five to six days usually needed. "We always want to be better. We're never complacent with being 'as expected,'" says Dr. Frantz.

Good heart hospitals work at staying on top. "It's not happenstance," says Mark Foust, chief marketing officer at CJW Medical Center in Richmond. "You need to look at your numbers. You need to have process improvement programs in place." CJW reviews how long it takes to get a patient from the emergency room to treatment, and what could be done better during the transition. The hospital is building a $44 million, 22-bed heart hospital at Chippenham, scheduled to open in mid-2003. CJW is part of the 180-hospital HCA corporation. About 70 of those hospitals do cardiac surgery; CJW is one of the 10 best in the corporation, Foust says. Also, in Fairfax County, Inova Health System broke ground last month on what will be the 156-bed Inova Heart Institute. It's scheduled to open next to Inova Fairfax Hospital in the spring of 2004.

No matter where you go in Virginia, patients can take heart in this fact: cardiac patients here fare slightly better than the national average. The mortality rate for cardiac patients in the state is 2.9 percent, compared to 3.2 percent nationwide. Still, what should a prospective heart patient in search of a good hospital do with data like that? Candice Saunders, COO of the Inova Heart Institute, thinks outcomes data like the VHI study can confuse consumers. She recommends starting with the Web as a place to get information. "The Web information leads people to questions and resources. It gives you an overview." Then, patients can broach questions with a doctor or hospital nurse prior to a hospital surgery.

Richmond resident Gene Louderback would agree. While reading about the VHI data three days before his bypass was comforting in a factual sort of way, he looked to his cardiologist for the greatest reassurance. "I rely on him and his recommendation meant the most to me." Yet as more information about outcomes and quality of service becomes available, future patients may begin to rely on statistics as much as their doctor recommendations.