Which hospital is better?

Many of us live in cities with more than one hospital. And, in most cities, one hospital is considered better than the other(s). Why?

An article by Edward Dolnick in the New York Times gives us a hint of how we “know” that one place is better than another. Because we expect it to be.

Huh? Well, as con artists know, you can take advantage of people’s expectations. Dolnick summarizes a test in which 32 volunteers were asked to sample strawberry yogurt, in the dark. Then the subjects were given chocolate yogurt. “Nineteen of the 32 subjects praised the strawberry flavor.”

When it comes to hospitals, we can measure “better” according to a variety of metrics, ranging from decor and food to the friendliness of the staff to the clinical outcomes achieved for different kinds of diseases. I don’t know about you, but the one I like the best is the likelihood that I will not be harmed during my time in the hospital. After all, hospitals are one of the leading public health hazards in America, and when I go to one, I would like to leave feeling better than when I arrived.

But, you may have a different set of criteria. That’s OK. Each of us knows what is really important to us, right? But I am guessing that most of us fundamentally care about something related to the actual quality of medical care offered.

Here’s a test for those of you who live in the Boston area (or New York or London or New Delhi or wherever). Which is the best hospital according to the criteria that you hold dear? Write down that answer.

Now, what evidence do you have for your conclusion? If you are basing your choice on clinical outcomes, do you have statistically valid data? Without knowing what metrics you have chosen, I will tell you categorically that you do not. There may be some publicly available data about some clinical outcomes and medical processes, but I will assert that it is many months or years out of date, and not necessarily reflecting the service you will get. In short, that data currently gives an impression of precision that is not valid.

(Yes, there are differences in culture and approach in the various hospitals, and those might make you feel more or less comfortable and happy, but do you mind if we focus right now on the measurable outcomes of clinical care?)

The truth is probably that you think your chosen hospital is the best because your primary care doctor, whom you trust, referred you there. But how does your doctor know which is the best? Well, you say, “He is an expert.”

To which Dolnick notes, “Experts make the best victims because they jump to unwarranted conclusions.”

As mentioned below, Brent James from Intermountain Health makes a persuasive case that the variation in medical care from region to region is not based on scientific evidence, but is a function of “medical mythology," lessons of habit passed down from one generation of doctors to the next. I haven’t asked him, but I would guess that he would also support my proposition that referring doctors often make medical judgments for their patients based on unsupported expectations about the relative efficacy of treatment between hospitals. (I put aside issues of personal relationships and financial integration and gain for purposes of this discussion, but we know those are important determinants of referral patterns.)

Now, before you fret too much about what I have just said and start to worry that you are not being sent to the “best” place, I will make another categorical assertion. I will confidently state that, with very few exceptions, you will get comparable care in most if not all of the hospitals in your home city.

Since “the best” is an elusive goal, on what should you focus? Wherever you go, the most important thing you can do is to bring along a trusted family member or friend to be your advocate, to help you keep track of what is going on, ask pertinent questions, and to help make sure that the plan of care is carried out properly. (Read Nick Jacobs’ book for more advice on this front.)

Another thing you might want to consider (he says, in a totally self-serving manner!) is whether the hospital you are visiting has made an institutional commitment to quality and safety improvement and reduction of harm -- and whether it is willing to hold itself accountable by publishing current clinical statistics as to its progress in meeting audacious goals in that domain. A hospital that is aggressive in setting quality and safety expectations; is modest in how much it knows and how much it needs to learn; and shares it successes and failures with others throughout the medical world, should give you some satisfaction that they are thinking about you more than about themselves.