Healthy on the Surface : Medical care: The county offers talented physicians and high-quality facilities. But the system has gaps--and symptoms of future problems.

When gynecologist Ronna Jurow came to Ventura County a decade ago, after teaching at USC School of Medicine and practicing at Cedars-Sinai Medical Center in Los Angeles, she figured she’d found her way to the backwoods of medicine.

She saw Community Memorial Hospital in Ventura and thought, “Look at this little bitty hospital. What do they know? But I was wrong.”

What Jurow says she found instead--at Community and at St. John’s Regional Medical Center--were excellent labor-and-delivery programs.

“The care here is underrated,” she said. “We tend to underrate ourselves because there is this small-town image. But I know the people at Cedars. We all trained together. The difference is they pay $5,000 a month in overhead, and I walk around in cowboy boots.”

Ventura County residents still have to drive to Los Angeles for experimental treatments and super-specialties such as organ transplants and treatment for severe burns. There is no children’s hospital or cancer center here.

The west county needs another neurosurgeon, Simi Valley another female gynecologist and the east county an intensive-care unit for newborns, hospital administrators say.

There also are statistics that raise questions about the quality of care at some of the county’s eight hospitals, including a rate of Cesarean-section births far higher than state and national averages.

In addition, a financial crisis that threatens the survival of several small community hospitals could cause other problems in the future.

The demise of these hospitals, doctors say, could create not only inconvenience and unemployment, but a larger gap in care that could cost lives during emergencies and diminish the overall quality of treatment in the county.

At the same time, the number of poor and uninsured patients in this county is up dramatically. And the money to pay for their medical care is down. That has forced a sharp cut in field nursing that some experts say could jeopardize the county’s health in the future.

But the gaping holes that once pocked county medical care have largely been filled. As the county’s population has soared--77% since 1970--the number of physicians has jumped 163%.

In nearly every medical specialty, Jurow said, “I’ve found good people here I can refer (patients) to.”

Even in family-practice medicine, where a nationwide shortage exists, Ventura County seems well stocked. About 14% of county doctors are general practitioners, compared to 9% statewide. And when Pleasant Valley Hospital in Camarillo went looking for four family doctors this year, it had no problem finding them, administrators say.

“We’re fortunate,” said Robert L. Quist, administrator at Los Robles Regional Medical Center in Thousand Oaks. “We’re closely situated to Los Angeles. It’s a very attractive area to live, and it’s low in crime. So there’s no shortage of physicians. We have a lot of talent out here.”

At a glance, statistics might indicate otherwise, since Ventura County has 21% fewer doctors per capita than the statewide average and 37% fewer general hospital beds.

But--because residents here are richer and healthier than California residents overall--the county also has 31% fewer hospital patients per capita than the state average and 41% fewer critically ill people in its emergency rooms.

Nor does Ventura County have a large medical research center or veterans hospital to lure doctors, or a large university teaching hospital--though 39 young doctors serve their UCLA family-practice residencies at Ventura County Medical Center.

Doctors generally say there is quality among the quantity in Ventura County.

Surgeon Philip L. Cardan, chairman of the credentials committee at St. John’s hospital, said he has been surprised by the resumes of newly arrived physicians, many of them trained at the nation’s best medical schools.

“They’re top-flight,” Cardan said. “I think it’s unique that you would have a little town like Oxnard, and have such a good hospital (staff).”

Some local hospital programs have strong reputations. The heart-surgery unit at Los Robles is one of the busiest in the region. The neurosurgical team that operates at Ventura’s two hospitals, St. John’s in Oxnard and Pleasant Valley in Camarillo is widely respected. The same is true for several general surgeons at Community and St. John’s.

The county hospital’s UCLA residency program is rated among the best for family practice in the country, luring top medical students nationwide and a cluster of talented teachers who also practice there. The county hospital’s AIDS and pediatric clinics and its neonatal intensive care unit are also known for their access and care.

Nearly all of the county’s eight general hospitals fare well on state inspections in such fundamentals as record-keeping, nursing services and quality control, records show.

“We don’t see any major problems in Ventura County,” said Lana Pembley, who oversees inspections in Ventura County for the state Department of Health Services.

And in recent years, none of the hospitals has had its accreditation threatened by surveys, taken once every three years by a private licensing committee, that monitor performance on 2,000 industry standards, administrators say.

That does not mean that health care is uniform throughout the county, from hospital to hospital and doctor to doctor. As in any profession, there are varying levels of skill and quality, doctors say.

But finding the excellent--and identifying the marginally adequate--is a problem.

Even physicians trained to analyze the quality of health care say fulfilling that task is confoundingly difficult. Some say that even the most diligent consumer has little chance of prejudging the performance of a hospital.

“Nobody can define quality,” said Samuel Edwards, medical director at the county hospital. “That’s what the United States has been struggling with for a long, long time.”

The best test of quality is hands-on experience or the judgments of other patients, said Edwards, who is chairman of the medical advisory committee of the Hospital Council of Southern California.

“The true test is the absence of negatives,” he said. “You can’t have Grandma complaining.”

For surgeries and special tests, health professionals use a more empirical rule of thumb: The more often a doctor or hospital staff performs a procedure, the better they usually are at it.

“If I have open-heart surgery, I don’t want to go to a place that does six a year. I want to go to a place that does 500 a year,” said Monty Clark, a spokesman for the regional hospital council.

“If I have an accident and a head trauma, I hope I wake up and say, ‘Take me to Ventura County Medical Center,’ ” said Pierre Durand, administrator of the county hospital, which has the busiest emergency room in the area. “Because of the volume we have here, our physicians are well practiced.”

Complaint Files

A window into the quality of care at Ventura County hospitals is provided by the inspection-and-complaint files kept by the state Department of Health Services.

State surveyors join national accreditation teams that descend on hospitals at least every three years. They also investigate patient complaints and sometimes do quality spot checks for federal health agencies.

The most widespread problem at a local hospital in recent years was found at Ojai Valley Community in December, 1990, when state inspectors discovered so many deficiencies that the federal government threatened to stop sending elderly and disabled Medicare patients there.

“The deficiencies identified have been determined to be of such a serious nature as to substantially limit your hospital’s capacity to render adequate care. . . ,” the hospital was told by the U. S. Department of Health Services in a Medicare termination notice in February, 1991.

Inspectors found that the hospital failed to meet state standards in several areas.

Its outpatient physical-therapy clinic was unlicensed; it had no effective quality-assurance program; a nurse rather than a doctor supervised the emergency room during a late-night shift; dust and ants were found in a food-storage area; and nearly 1,000 patient records had not been filed, even though some dated back more than a year, the report said.

Jim Bennett, an executive who was hired by the hospital shortly after the state inspection, said all the problems were corrected promptly and the facility kept its Medicare contract.

“There were significant areas identified that needed improvement,” Bennett said. “And there were extreme measures taken to get those in line as soon as possible.”

Inspections last summer showed that the Ojai hospital had no major problems meeting state and federal standards, he said.

Los Robles hospital, though cited for relatively few deficiencies in recent surveys, was cited in 1990 for not reporting the death of a 75-year-old patient who died after being given the wrong type of blood.

The state required that an “unusual occurrence” form be filed with the county health officer and the state.

Los Robles’ Quist said the mix-up was a matter of human, not procedural, error.

“We have a very active blood bank,” he said, “and in 20-some years this has never happened before.”

Los Robles was cited again a year ago for what a state inspector described as a problem of “major proportions” in its enforcement of sanctions against doctors who had not completed the paperwork in patients’ files.

A doctor, who was unidentified, was still seeing patients, the report noted, even though he had accumulated 180 days of suspensions for not filing patient histories, operating notes and medical summaries when discharging patients. Ten other doctors also faced more than 30 days’ suspension for not keeping their records up to date, the report said.

Quist said the problem has been resolved. But he said he does not think the suspensions for incomplete medical records indicate a quality problem.

“All it is,” Quist said, “is an indication that you have individuals who do not care to keep their paperwork up.”

Indicators

Beyond state inspections, word of mouth and common sense, there are sentinel measurements considered signs of potential problems at hospitals in this county and nationwide.

Since the mid-1980s, the U. S. Health Care Financing Administration has reported the death rates of Medicare patients by hospital in an effort to help the public make better decisions about health care.

The most recent report, released in June, shows that St. John’s hospital and Ventura County Medical Center had Medicare death rates significantly higher than predicted in 1990. About 10% of California’s hospitals had rates that high.

While warning that the death rates are not a direct measure of care, acting HCFA Administrator William Toby Jr. said the information could be “especially valuable to hospital administrators . . . by indicating potential quality problems in their facilities.”

At both local hospitals, administrators said Medicare death rate projections are flawed because they don’t adequately take into account the severity of patients’ illnesses--a criticism that has been made by some health-policy experts for years.

Durand at the county medical center and Daniel R. Herlinger, president of St. John’s, said their hospitals always review deaths to make sure that they were not caused by bad care.

“We review every mortality,” Herlinger said. But after receiving a letter from the HCFA about its findings this year, “we did another review, and we didn’t find any issues.”

A hospital’s predicted death rate calculates a patient’s relative risk of dying, and accounts for factors such as age, sex, chronic disease and prior hospitalizations.

If higher-than-expected death rates persist for more than one year, the trend could be an indicator of a serious problem, health experts say. Neither St. John’s nor the county hospital had higher-than-expected rates in both 1989 and 1990.

Another indirect measure of quality--and one that has received much attention--is the number of open-heart surgeries, coronary angioplasties and cardiac catheterizations performed.

A minimum number is recommended by leading medical groups so that cardiologists maintain their proficiency and their ability to deal with complications. But many California hospitals have been doing too few to meet the standard.

An angioplasty is a technique to open clogged arteries by threading a balloon-tipped tube through a vein to the heart. A cardiac catheterization is a diagnostic procedure in which a tube is inserted into the heart to release a dye.

Of the three Ventura County hospitals offering heart surgery, the cardiac center at Los Robles hospital, which is open seven days a week, accounted for about half of all heart operations and diagnostic procedures in 1991.

Its surgeons approximately doubled the 200-a-year recommended minimum for angioplasties and the annual minimum of 150 open-heart surgeries. It performed 1,754 cardiac catheterizations, compared to a recommended minimum of 200.

Community Memorial also exceeded the minimum standards in all three categories, and St. John’s surpassed the minimum for open-heart surgeries and catheterizations. But for angioplasties, St. John’s had only half of the recommended 200. The numbers represent an improvement over 1989, when Community had only 30 angioplasties and St. John’s 74.

“The issue here is, what are your numbers?” said cardiologist George H. Hubert, who directs Los Robles’ heart center. “The surgeon has to do a lot to be good at it.”

Los Robles’ principal surgeon, Mohammed Gharavi, does about 600 open-heart surgeries a year at two different hospitals, Hubert said. And Hubert--who performed the county’s first catheterization in 1970--performed about 750 catheterizations last year, he said.

Community Memorial also recruited a heart surgeon two years ago who is part of a Bakersfield-based group that does 1,000 surgeries a year, said the hospital’s executive director, Michael Bakst.

St. John’s has increased its number of heart operations only marginally because one surgeon has retired, and the hospital, though actively recruiting, has not yet replaced him, Herlinger said.

A third high-profile indicator of medical practice--and critics say of medical quality--is the percentage of babies delivered by Caesarean section at each hospital.

The national rate for Caesarean deliveries, the most common major operation in the U. S., increased from 4.5% of all births in 1965 to a peak of 24.7% in 1988 before declining to 22.7% in 1990.

The advocacy group Public Citizen calls the operation a “national epidemic” and charges that nearly 500,000 are performed annually without good reason and at a cost of $1.3 billion.

The procedure, which is about twice as expensive as a vaginal birth, also carries an increased chance of complications, the group says. Many leading obstetricians consider 15% to 29% a desirable Caesarean rate.

Ventura County’s was 22.9% in 1991, compared to the preliminary statewide rate of 21.4%. Rates ranged from a high of 32.1% at Los Robles to 15.8% at Ojai Valley Community. The rate in Westlake Community Hospital, just over the county line in Westlake Village, was 44%.

Generally, hospitals with affluent patients have a higher percentage of Caesarean deliveries, according to several doctors and administrators.

“I am shocked at the C-section rate in this area,” said Michael Feinman, a reproductive endocrinologist in Westlake.

He said doctors tend to favor Caesarean sections because they carry less chance of a lawsuit, and less chance of injury to the baby--and because of the convenience they offer to both doctor and mother.

“It boggles my mind,” Feinman said. “A lot of women with comfortable means tend to prefer C-sections. I’ve met a significant number who would rather not bother with labor. With C-sections, they think they have more control over the pain.”

Other doctors said white-collar communities have more Caesarean deliveries because expectant mothers tend to be older than those in poorer communities, making vaginal deliveries more hazardous.

Amid the controversies surrounding reports on the necessity and results of medical care, the state Department of Health Services expects to produce by mid-1993 its own list of benchmarks that consumers can use to judge hospital quality.

In its first annual report, the department will rank all 500 acute-care hospitals in the state by outcomes in three areas--heart attacks, a type of back surgery and births. The report is expected to expand the rankings to nine areas by 1995.

In the end, however, doctors say patients are not likely to judge their hospitals by the latest state report.

“People are as loyal to their hospital as they are to their political parties,” said the county medical center’s Edwards. “They either love them or hate them. . . . And frankly, they don’t have any idea about the carotid artery complication rate in a hospital.”

Much the same is true for attitudes toward doctors. Patients judge them on the efficiency of their service, not on the quality of care, Edwards said.

“Why is it that the doctors of the rich and famous tend not to be the medical leaders inside the profession?” Edwards asked.

“These people would tell you,” he said, “that what they care about is what they were told when they called for an appointment, how long they waited for the doctor, did their gowns fit, did they get their tests back quickly and were the nurses who drew their blood polite and friendly.”

For a surer gauge of the quality of medical care, researcher Robert Brook, director of the health science program at Rand Corp. in Santa Monica, said there are three things patients should keep in mind when seeking treatment.

“First, if you need it, you want it, but if it will hurt you without improving your health, you don’t want it. Second, you want it done well. And third, you want to be treated like a human being.”

Choosing a Hospital

In decades past, some Ventura County residents felt they needed to travel to Los Angeles County to receive complete health care. But a sampling of opinion among residents today indicates that many have faith in the quality of treatment provided by Ventura County hospitals. Residents were asked this question: If you or a member of your family had a serious illness or major injury, would you want to go to a Ventura County hospital for treatment or to one in Los Angeles County?

Gary Auer of Thousand Oaks, FBI supervising agent in Ventura

“We would go to Los Robles hospital. Each and every time any member of my family has had an emergency, we’ve gone there and had an outstanding response and highly professional care. And in recent years, a number of my agents assigned here have had various operations, some serious, and every single one went to Los Robles hospital and received outstanding care. In my mind, they’re terrific.”

Sandi Bush of Camarillo, inactive nurse and former councilwoman

“I think it would depend upon the treatment required. For example, there’s a great burn center in Sherman Oaks. But I understand there are some very good cardiologists here in Ventura County. So if I needed a heart surgeon, I would seek referrals from my own doctor and people I know who have gone through the procedure. I had some minor surgery at Pleasant Valley Hospital, and that’s a great hospital. The people are very friendly. It’s small enough the people know you. I have never heard anything negative about Pleasant Valley, and I’ve lived in Camarillo over 17 years.”

Stan Greene of Ojai, president of Citizens to Preserve the Ojai

“I really don’t have any experience with the hospitals here at all, except for our local one here in Ojai. I had sort of an emergency, so I went there. But if it were for some specialty, I wouldn’t hesitate to go to a Ventura hospital. I’d take the advice of my local physician on which one. If it were something that required a special institution, like the one UCLA has for vision, I’d go there. And if it had to do with a cancer I might go to L. A. or the Sansum Clinic in Santa Barbara.”

Carmen Ramirez of Oxnard, executive director of Channel Counties Legal Services

“I’ve lived in L. A. County. And I go there all the time. But everybody would rather go to see a doctor or to a hospital in their hometown. I’d probably go to St. John’s. I’ve been a patient at Community Memorial. I’ve had friends, family and clients at Community Memorial, Ventura County (Medical Center), Santa Paula (Memorial Hospital), St. John’s and Los Robles. And they’re all good, I think. I do know something about the hospitals in L. A., and if one has the misfortune of not having good medical insurance, you could wind up in a facility where you have to wait in the halls for hours. That happened to my sister. She waited about eight hours with terrible pain while people ahead of her were treated for gunshot wounds.”

Greg Stratton of Simi Valley, mayor and Teledyne manager

“I don’t know if I’d have a heart transplant here in Ventura County. But Los Robles has a fairly good reputation (for heart surgery). A guy I work with had that done over there, and I think I would feel secure going over there for those types of things. There are some cardiac procedures that can be done at the Simi hospital. Our local hospital does not do some kinds of specialties, but there are a lot of things they do very well. I think the hospital’s rated very well in terms of people having babies and for a lot of general surgeries. (The specialists) that do the more esoteric stuff will say, ‘Hey, you need to go over to Los Robles or to the Valley.’ ”

Barbara Thorpe of Oak View, nursing professor, Cal State Dominguez Hills

“For the real tricky high-level sub-specialties I probably would go to L. A., either to UCLA for cancer or maybe to Cedars-Sinai for eye or other special problems they handle at their institutes. But if it were your standard appendectomy, gallbladder or general surgery, I’d stay here and probably go to Community Memorial. Just recently my husband had a real acute food poisoning and went into shock, and Ojai Valley (hospital) did a fabulous job with us. And they got my sister two years ago. A bee sting turned into this massive allergic reaction and they just did a wonderful job for her. I think we’ve got some really good health care in Ventura County, it’s just that everybody needs access to it.”

Donald A. Villeneuve of Ventura, anatomy instructor at Ventura College

“I’d go to Community Memorial Hospital. Inadvertently we’ve used it quite a bit in the last few months. And the care was excellent. My wife twisted her ankle rather severely and went to emergency. I almost sliced my finger off. And then my mother, who is 87, had her arm amputated in November. This was really pretty critical. But she was released from the hospital in three days back to a full-care convalescent home and everything has gone smoothly. The orthopedic surgeon did an incredible job. In my research, I’ve spent a lot of time in Los Angeles hospitals. . . . And if I got hit on the street in Los Angeles, I’d ask them to bring me up here. I’ve been to emergency in the county hospital here, and by comparison it’s like being in an upscale private hospital. It’s just the sheer weight of numbers. They’re overwhelmed down there.”

Richard Wittenberg of Ventura, county chief administrative officer

“There’s no question that I would go directly to Ventura County Medical Center. It is a unique county hospital. It is connected to UCLA (medical school) as a teaching hospital, and as a result the quality of care is excellent. I have gone there, and my son went there with a broken leg and had some heavy-duty surgery. It was terrific. The western end of Ventura County has a cluster of outstanding physicians. They practice at VCMC and cross-pollinate at Community Memorial and St. John’s.”

Births by Cesarean Section (By hospital, as percent of total births)

Los Robles Regional Medical Center: 32.1%

Simi Valley Hospital: 29.8%

Pleasant Valley Hospital: 29.1%

Community Memorial Hospital: 25.6%

St. John’s Regional Medical Center: 21.1%

Santa Paula Memorial Hospital: 20.7%

Ventura County Medical Center: 17.2%

Ojai Valley Community Hospital: 15.8%

COUNTYWIDE: 22.9%

STATEWIDE: 21.5%

*

Cesarean Section Deliveries (Ventura County) 1983: 20.8% 1984: 23.1% 1985: 23.4% 1986: 25.4% 1987: 25.5% 1988: 24.9% 1989: 25.5% 1990: 23.3% 1991: 22.9% Sources: Office of Statewide Health Planning and Development; State Department of Health Services

Hospital Profiles

Total Bed Avg. Avail. Occ. Stay Emerg. Founded Beds Rate Days Admit Community Memorial 1901 230 59.0% 4.9 2,653 Hospital (nonprofit) Los Robles Regional 1968 220 46.2% 4.9 2,437 Medical Center (for profit) Ojai Valley Community 1960 116 50.7% 12.5* 339 Hospital (for profit) Pleasant Valley 1974 180 66.8% 12.3* 1,303 Hospital (nonprofit) St. John’s Regional 1912 223 78.7% 6.3 4,341 Med. Center (nonprofit) Santa Paula Memorial 1961 60 42.5% 4.2 1,361 Hospital (nonprofit) Simi Valley Hospital 1965 209** 46.3% 6.4 2,142 (nonprofit) Ventura County 1887 148 93.0% 4.9 5,629

Inpatient Surgeries Births Community Memorial 3,659 2,258 Hospital (nonprofit) Los Robles Regional 2,835 1,222 Medical Center (for profit) Ojai Valley Community 418 202 Hospital (for profit) Pleasant Valley 1,292 766 Hospital (nonprofit) St. John’s Regional 4,288 1,687 Med. Center (nonprofit) Santa Paula Memorial 729 305 Hospital (nonprofit) Simi Valley Hospital 1,745 840 (nonprofit) Ventura County 2,969 3,895

*Medical Center (public)

* Stays are longer because of large skilled nursing units.

** Simi Valley now has 159 available beds.

Note: Available bed, occupancy rate and hospital stay data is from 2nd quarter, 1992. Admissions, surgeries and births are totals for 1991.

Source: Office of Statewide Health Planning and Development

*

Hospital Patient Payments

Average Average Average Patient Patient Outpatient Payments Payments Per Payments Per Day Full Stay Per Visit Community Memorial Hospital $1,479 $7,268 $422 Los Robles Regional $2,755 $13,450 $304 Medical Center Ojai Valley Comm. Hospital $586* $7,347 $357 Pleasant Valley Hospital $916* $11,250 $402 St. John’s Regional $2,090 $13,231 $337 Medical Center Santa Paula Mem. Hospital $1,520 $6,353 $233 Simi Valley Hospital $1,601 $10,225 $303 Ventura County Medical Center $1,395 $6,796 $219

* Payments are lower because of large skilled nursing units

Note: Averages are for 2nd quarter, 1992

Source: Office of Statewide Health Planning and Development

Heart Procedures, 1991

Only three Ventura County hospitals perform heart surgeries.

To maintain an adequate standard of practice, the American College of Physicians, the American College of Cardiology and the American Heart Assn. recommend that 200 angioplasties be performed annually at a hospital.

In open-heart surgery, the American College of Surgeons and the state Department of Health Services recommend that at least 150 operations be performed annually at a hospital.

For cardiac catheterization, the state Department of Health Services recommends at least 200 operations be performed annually at a hospital.

Open Heart/ Bypass Angioplasty Los Robles Regional Med. Center 280 427 Community Memorial Hospital 194 204 St. John’s Regional Med. Center 151 100

Cardiac Catheterization Los Robles Regional Med. Center 1,754 Community Memorial Hospital 993 St. John’s Regional Med. Center 684

*

Medicare Death Rates

When compared with their predicted 1990 death rates two of eight hospitals in Ventura County had higher than expected rates--Ventura County Medical Center and St. John’s Regional Medical Center.

The data from the U.S. Health Care Financing Administration reflects the percentage of a hospital’s Medicare patients who died within 30 days of being admitted, whether they were still patients or had been discharged. The national average 30-day mortality rate was about 9.0%. The California average was 9.6%

Mortality rates for all causes by hospital, 1990

Medicare Predicted Actual Patients Death Rate Death Rate Community Memorial Hospital 1989 2,377 8.2% 8.8% 1990 2,048 8.0% 8.6% Los Robles Regional Medical Ctr 1989 1,595 8.4% 8.2% 1990 1,664 7.9% 8.6% Ojai Valley Community Hospital 1989 520 10.2% 8.8% 1990 525 10.2% 11.4% Pleasant Valley Hospital 1989 964 8.4% 8.5% 1990 1,022 10.1% 9.5% St. John’s Regional Medical Ctr 1989 2,153 8.8% 9.1% 1990 2,154 8.1% 10.3 Santa Paula Memorial Hospital 1989 610 11.4% 11.0% 1990 614 11.8% 13.7% Simi Valley Hospital 1989 841 10.2% 9.5% 1990 720 10.3% 9.9% Ventura County Medical Center 1989 355 9.1% 12.1% 1990 339 9.1% 13.6% CALIFORNIA 1989 556,171 9.4% 9.9% 1990 528,454 9.2% 9.6% NATIONWIDE 1989 6,392,842 9.0% 9.0% 1990 6,542,299 9.0% 9.0%

Standard Deviation Community Memorial Hospital 1989 0.6% 1990 0.8% Los Robles Regional Medical Ctr 1989 0.7% 1990 0.9% Ojai Valley Community Hospital 1989 2.2% 1990 1.7% Pleasant Valley Hospital 1989 1.0% 1990 1.0% St. John’s Regional Medical Ctr 1989 0.8% 1990 1.0% Santa Paula Memorial Hospital 1989 2.3% 1990 1.7% Simi Valley Hospital 1989 1.2% 1990 1.3% Ventura County Medical Center 1989 2.2% 1990 2.2% CALIFORNIA 1989 0.1% 1990 0.1% NATIONWIDE 1989 0.0% 1990 0.0%

Note: If the margin between the actual mortality rate and the predicted mortality rate is more than twice the standard deviation then a hospital’s rate is considered higher than expected.

The predicted mortality rate takes into account characteristics of individual patients. These include age, sex, previous hospitalization, other chronic illnesses, emergency or non-emergency admission status, admission source such as a nursing home or hospital transfer, as well as the number of patients treated at each hospital.