Hospital-Level Cardiovascular Management Practices in Kerala, India

Abstract

Background Hospital management practices are associated with cardiovascular process of care measures and patient outcomes. However, management practices related to acute cardiac care in India has not been studied. Methods and Results We measured management practices through semistructured, in-person interviews with hospital administrators, physician managers, and nurse managers in Kerala, India between October and November 2017 using the adapted World Management Survey. Trained interviewers independently scored management interview responses (range: 1-5) to capture management practices ranging from performance data tracking to setting targets. We performed univariate regression analyses to assess the relationship between hospital-level factors and management practices. Using Pearson correlation coefficients and mixed-effect logistic regression models, we explored the relationship between management practices and 30-day major adverse cardiovascular events defined as all-cause mortality, reinfarction, stroke, or major bleeding. Ninety managers from 37 hospitals participated. We found suboptimal management practices across 3 management levels (mean [SD]: 2.1 [0.5], 2.0 [0.3], and 1.9 [0.3] for hospital administrators, physician managers, and nurse managers, respectively [ P=0.08]) with lowest scores related to setting organizational targets. Hospitals with existing healthcare quality accreditation, more cardiologists, and private ownership were associated with higher management scores. In our exploratory analysis, higher physician management practice scores related to operation, performance, and target management were correlated with lower 30-day major adverse cardiovascular event. Conclusions Management practices related to acute cardiac care in participating Kerala hospitals were suboptimal but were correlated with clinical outcomes. We identified opportunities to strengthen nonclinical practices to improve patient care.

Keywords: acute coronary syndrome; hospital administrators; infarction; leadership; organization and administration; patient care; quality improvement.

Figure 1.

Flowchart of recruitment of hospitals and participants, including types of managers included for analysis. Depending on individual hospital management structure, managers come with various names, and to participate in the study, managers must have the responsibility of managing other staff. ^*2 nurses were identified for management interview at one hospital.

Figure 2.

Mean (95% CI) responses of 90 participants, stratified by role, to each survey item and aggregated management practice processes (implementation, monitoring, and use). Avg =mean score (SD); overall=hospital administrator 2.1 (0.5), physician manager 2.0 (0.3), nursing manager 1.9 (0.3), operation=hospital administrator 2.7 (0.5), physician manager 2.6 (0.3), nursing manager 2.3 (0.3), performance=hospital administrator 2.4 (0.7), physician manager 2.2 (0.6), nursing manager 2.2 (0.6), targets=hospital administrator 1.5 (0.6), physician manager 1.4 (0.4), nursing manager 1.1 (0.2), talent=hospital administrator 2.2 (0.7), physician manager 1.9 (0.4), nursing manager 2.1 (0.4) I=implementation, U=usage, M=monitoring See Supplemental Table 1 for corresponding management practice.

Figure 3.

Heat map of correlation between individual item responses and post-intervention 30-day major adverse cardiovascular event (MACE) rates, defined as death, re-infarction, stroke, or major GUSTO bleeding in the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) randomized trial. See Supplemental Table 1 for survey item and its corresponding number under each management domain. Green represents a negative correlation: higher management practice is associated with lower event rates (more favorable correlation). I=implementation, U=usage, M=monitoring