Not Every Hospital Is Created Equal
Paul Maurice momentarily lost consciousness while biking on a trail early one morning near his home in Whittier. Paramedics rushed him to the closest hospital, a small community facility that didn’t have a trauma unit. He seemed dazed and confused to his wife, Phyllis, who arrived shortly after he was admitted. There was no MRI at the hospital, so doctors didn’t perform a brain scan to see what had triggered the blackout.
That evening, Maurice, 60, suffered a massive cerebral hemorrhage, and three days later he was dead. “Other doctors have since told me that Paul should have been given an MRI,” insists his widow, Phyllis. “If he had been taken to a hospital that was better equipped to deal with emergencies, he would still be alive today.”
Can a hospital make such a difference? You bet, say experts. In fact, the American College of Surgeons strongly urges dispatching trauma victims like Maurice to regional trauma centers--typically major hospitals such as Cedars-Sinai Medical Center in Los Angeles or Huntington Memorial Hospital in Pasadena--that have the high-tech tools and expertise to handle critical injuries. And it’s not only accident cases in which the experience of the hospital can make the difference between life and death.
Busier Hospitals Have Lower Mortality Rates
Studies show that mortality rates are as much as 64% lower at busier hospitals for a number of complicated procedures, ranging from heart and other organ transplants, coronary bypass surgery, pancreatic and esophageal cancer surgery, and angioplasty to the management of chronic conditions like asthma, diabetes and HIV-AIDS. Patients fare better overall, too, and have fewer complications, bleeding problems and infections.
Yet few consumers, while deciding which health plan or doctor to choose for medical coverage, consider the track record of the hospitals where, if necessary, their doctors would send them. When patients select a primary care doctor, they often fail to notice that the medical group to which the doctor belongs is affiliated with one or two particular hospitals. At Kaiser Permanente, the nation’s biggest HMO, members generally are required to receive treatment only at Kaiser hospitals.
But this oversight can have serious consequences, particularly for those with chronic conditions, like heart disease, or a family history of ills such as breast or colon cancer.
“Surgeons are viewed as the captain of the ship, and patients are always concerned about their doctor’s credentials,” says Dr. John D. Birkmeyer, a surgeon at Dartmouth College in Hanover, N.H., and a senior research associate with the U.S. Department of Veterans Affairs. “But the fact is that where your surgery is done or your disease is treated is even more crucial.”
During the last 25 years, in fact, more than 100 studies have shown that patients do better at hospitals where procedures are performed more frequently. This intuitively makes sense, but it’s not just that practice makes perfect.
“Hospital volumes are a proxy for other things,” says Dr. Arnold Milstein, medical director of the Pacific Business Group on Health, an employers’ coalition in San Francisco. Busier hospitals normally have a better overall package: more sophisticated intensive care units staffed by seasoned doctors and nurses who know how to cope with emergencies, well-stocked blood banks that can support a major bleed if a patient starts to hemorrhage, state-of-the-art equipment like MRIs, and standardized systems for dealing with unstable and critically ill patients.
The numbers tell the story. A 1999 study published in the Journal of the American Medical Assn. identified 11 risky medical procedures and conditions where the experience of a hospital is critical. The researchers found that patients undergoing repairs of weak spots or tears in their aorta artery had a 64% higher death rate than those operated on at hospitals with sufficient experience. Similarly, heart transplant patients were twice as likely to die at centers doing eight or fewer transplants annually, as compared with hospitals where the procedures were done more frequently. And children undergoing heart surgery at hospitals performing fewer than 100 of these procedures each year were 42% more likely to die.
The researchers came to a disturbing conclusion: Of the 120,000 California patients studied, more than 600 people died simply because they had been treated at hospitals with limited experience. That translates to more than 4,000 avoidable deaths a year in the United States--a figure about equal to the number of passengers on a dozen jumbo jets.
A hospital’s experience level can impact long-term survival, too. Other recent research showed that breast cancer patients were twice as likely to be living five years after surgery if their operations were performed at hospitals that did 150 or more procedures a year, contrasted with facilities that did 10 or fewer. And even the treatment of chronic conditions, like asthma or diabetes, which can quickly escalate into grave health crises, was superior at the busier centers.
Big Business Moves to Raise Care Standards
This research has not been lost on major corporations. Some of them are teaming up with U.S. public health officials to use this information to improve the quality of care. On Tuesday, in fact, members of the Leapfrog Group, a nonprofit consortium of benefit managers at Fortune 500 companies like General Motors, General Electric and Bank of America, along with representatives from the Health Care Financing Administration, will convene in Washington, D.C. Their goal is to use the clout of their collective purchasing power to pressure health-care providers to upgrade safety standards.
A cornerstone of their effort is to have higher-risk procedures performed at high-volume hospitals, which they call “centers of excellence.” Their initiative also calls for the installation of computer systems in hospitals to order prescriptions, which can intercept more than 50% of serious prescribing errors, and staffing intensive care units with trained ICU doctors, which cuts risk of death by more than 10%.
“We’re asking employers to implement proven ways of slashing death rates and improving care,” explains Peter V. Lee, president of the Pacific Business Group, which negotiates health-care coverage for large California employers, including Southern California Edison.
Of course, while volume is correlated to quality, it’s no guarantee that you’ll get the best care, and many smaller hospitals do offer fine service. What’s more, you don’t need the services of a top-notch heart surgeon for a routine appendectomy.
Educated Consumers Make Better Choices
Still, volume is a good yardstick. And it’s just plain common sense to check out the hospitals in a health plan’s network as you make a choice about medical insurance. This is particularly important if you’re prone to certain disorders or suffer from, say, high blood pressure or heart disease, or are contemplating getting pregnant but know it’s risky--if, for example, you’ve had complications with previous pregnancies or you’re over age 35.
You’ll need to do some legwork to check out hospitals in your area. Ask the customer service representatives at local hospitals for numbers on specific procedures--for example, how many coronary artery bypass grafts are done at the hospital annually. Most hospitals collect this data, so don’t be intimidated.
“If they can’t or won’t give you the information,” says Dartmouth’s Dr. John Birkmeyer, “that’s a red flag.”
If you have a specific condition, such as breast cancer, diabetes or HIV-AIDS, contact local support groups. “They can give you the names of the top docs in that specialty,” says Bridget Sheehan-Watanabe, a health policy analyst for the Center for Health Care Rights, a Los Angeles consumer watchdog group. Then find out to which hospitals these doctors admit their surgical patients, since a top doctor is likely to want to be affiliated with a good hospital.
Two Internet sites, one sponsored by the Pacific Business Group and the other by Healthgrades.com, also provide report cards on area hospitals for various procedures based on the frequency that they do them.
If a particular hospital is not in your health plan’s network, consider adding what’s called a “point of service” option. This allows you to go outside of the plan’s network of doctors and hospitals. The downside: You’ll pay higher premiums and out-of-pocket expenses, which could run into the thousands of dollars for complicated surgeries or extended hospital stays. Another alternative is to switch to a PPO, or “preferred provider organization,” where you can go to any hospital but the plan only covers a percentage of the costs.
If you’re in an HMO that severely restricts choice--a recent study found that 40% of Californians in health plans have no choice of hospitals--you can file an appeal with the health plan’s administrators. But you must prove to them that you have a good reason for going elsewhere. However, providers like Kaiser already do refer patients to the high-volume centers in their system.
But you have to be vigilant, and stay on top of changes in your medical benefits. Just because a hospital is in the network one day doesn’t mean it will be the next.
Information Is Just a Click Away
* Http://www.healthscope.org: This nonprofit site is sponsored by the Pacific Business Group on Health and includes information on most Southern California hospitals. You’ll find data on such things as C-section rates; patient survival rates after organ transplants; heart attack survival rates; angioplasty; rates of newborn rehospitalization; abdominal aortic aneurysm surgeries; heart attack survival rates; coronary artery bypass grafts; survival rates of premature babies; and carotid endarterectomy.
* Http://www.healthgrades.com: This is a commercial site that provides ratings for most Southern California hospitals on a wide range of procedures, including back and neck surgeries, coronary bypass operations, heart attack survival rates, obstetric procedures and C-sections, spinal fusions, and knee and hip replacements.
