Tuesday, September 02, 2008

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available data about some clinical outcomes and medical processes, but I will assert that it is many months or years out of date, and not necessarily reflecting the service you will get.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.


Sarah said...

And here I thought the best hospital was the one where your dad worked!

Paul Levy said...

Well, that is probably correct.

Gail said...

Choosing is really a crap shoot, and has more to do with wanting and believing that the hospital will be great rather than the hospital actually being great. And…as you said it has most to do with the doctor who refers you. If he thinks it’s great, then you will. You have to. In addition, because you have this belief, you have a placebo effect with your outcome. So, the best thing a hospital can do is not mess up your karma!

www.mostemailednews.com said...

Good post. It makes sense. I personally look for cleanliness when I am making a hospital visit. I figure if they can't bother to keep it clean, I shouldn't trust anything else.


Anonymous said...

Patients choose a hospital based on the numerous criteria's that you mentioned above. But quite a few people want to ensure that the hospital has religious affiliations.


AsTiMa said...

I could quite possibly in the minority, but I don't believe that the hospital I work for is the best in town. I also don't believe it is any worse than the other one we have here. Yes, I live in a huge town with two whole hospitals. Ours is still a non-profit (HA!), while the other has recently become for-profit. They have the aesthetic vote, if that is something people look for, and you know they do, but we have equally competent and caring staffs. I know this from both personal experience and from what I gather from others. As far as an employee standpoint, the other place pays more hourly, but we have a better benefit package. I guess it completely boils down to personal choice because I don't have any of the stats about what should matter... Infection rates, complaints about staff, insurance fraud. And I completely agree with Lee, cleanliness is HUGE for me! When it comes to making an informed decision, I only know what I see in our institution. Thanks for making people think about these things!

margalit said...

I think it depends on what you're going into the hospital for. I think the BI has the best maternity ward, which has been vastly upgraded since my kids were born. I was really impressed with it when I visited a patient a couple of weeks ago. I use the BI for my opthamology care because they have a specialist that the Brigham does not have.

For cancer, I'd do Dana Farber.

For my heart issues, I see cardiologists at the Brigham. I chose them because they have a practice that solely concentrates on women's heart disease, and one of my cardiologists is a specialists in my particular genetic disorder.

I'd always choose Childen's over any other hospital for my kids, although I use Newton Wellesley for their wonderful pediatric emergency room. If you haven't been there, go check it out. It's amazing.

The only hospital that I'm pretty unfamiliar with is Mass Gen. A family member with Burkett's Lymphoma died in their care, and when he was hospitalized it was depressing and poorly staffed. Even though that was years ago, I still feel uncomfortable using them for anything.

Eilyas. said...

the one with the most resources. that's where i'd rather be. i dont care how im treated, as long as i can be treated.

eyad said...

Wish we don't go to any hospital :)

book said...

good post

Barry Carol said...

If the quality of care at all (or at least most) of the hospitals in my town / city is comparable, then what I (and my insurer) should really be interested in is which one is the least expensive. Of course we would need good, user friendly price transparency tools, including episode pricing for expensive surgeries, to determine that.

Paul Levy said...

Your insurer has that information.

John said...

What about the methodology used by U.S.News in determining the Best Hospitals annually? Surely that means something and help in shortlisting the "better" hospital?

Allen said...

Maybe it's a cultural thing, but Americans like me tend to prefer simple ratings. For example, the US News annual ratings of doctors and hospitals, which if I remember correctly, is based on physician surveys that are subject to the "mythology" noted in Paul's blog. But having been witness to a large amount of inpatient care for my daughter over the past year, my opinion is that simple ratings are useless. What really matters are issues like communication between team members, access to advanced diagnostic and treatment options, technical skills of the staff, availability of nursing, social work and other staff to help patients deal with issues that arise, and so on. The dilemma is how to capture this information in a way that is useful to others as they consider where to get their care.

Molly said...

I used to think that cleanliness or the "niceness" of the staff was most important, until I had an error in a procedure happen.

Like any relationship, you can't judge it by when everything goes perfectly, but by when things go wrong and how they are resolved.

In my case, information from my history was not transferred to my procedure record, and I was given a medication that I should not have been given. The partial history that was taken on the day of the procedure did not include questions about this area, so I did not think to mention it again.

Once my specialist was informed of the error, he then implied that it was my fault, since I should have mentioned my past condition on the day of the procedure. I have received no support from the hospital either.

I have discovered over the years that you shouldn't form a lasting relationship with someone based on how he behaves on the first date, but more how he behaves during the first fight.

I guess choosing a hospital should be no different.

Paul Levy said...


I think Allen has given you a great answer.

Anonymous said...

That is a great answer from Allen; obviously from someone who's been there. I think most of what he mentions would be captured in the two metrics of outcomes and patient satisfaction, although these are rather blunt instruments.
ps the other day, for the second time, my retired orthopedist husband received snazzy color "Outcome Report" booklets from the Cleveland Clinic, regarding their Orthopedic and Rehabilitation services. They solicited his input on their usefulness. Now everyone knows this is a marketing tool, but their not-so-great outcomes were included, so at least they are not cherry-picking.


Anonymous said...

I have been admitted to two local hospitals in my town this last year. The first had a "hair" in my cranapple juice ( wont elaborate on which part of the body it came from ) , they mixed up my lab work with another patient, and treated me for someone else's issues. The second one blew up my vein during a cat scan and dumped the load of iodine into it. I got to stay two extra days with my arm elevated till the swelling went down. So, I pick.............................Don't get sick in Las Vegas !!

Stephi said...

Interesting topic of conversation as I prepare to have a baby. The hospital that I *should* be going to (in my neighbourhood) has a horrible reputation. Reputation as a "butcher shop". This coming from a nurse that works there! She even takes her children to another hospital. BUT, I had a good experience there a few years ago when I was taken there after having a seizure. They were incredibly efficient, speedy and so wonderfully kind. BUT, that was because they didn't know if it was a "head injury" and so I was rushed in. I would not want to have my baby there, as they have zero reputation (good or bad) for birthing. The hospital that I'm actually giving birth in, is known as the best in not only the province, but western Canada for Women's and Children's issues and birth, high-risk pregnancies, multiples, etc. I'm thrilled that I got in, they are just delightful. I talked to other mom's to get their experiences, opinions, etc. Word of mouth is a crazy thing.

Wendy said...

I work at a small (30 bed) community hospital. We are the only one in the immediate area. Our building is 50 years old and while in good repair, isn't "pretty" and we don't have the room for all of the latest and greatest in equipment. Unfortunately the assumption that we are not a good hospital is based on looks.
We are the first ones to admit that we don't have the capacity to do everything, and as a case manager I do my best to make sure that the arrangements are made for the patients at alternate facilities.
It is a strange thing that we get glowing reviews from people brought in from out of town, but those who come to us from in town say we're doing a crap job. Go figure.
Thank you for you blog Mr. Levy.

Dr. Mounir Bashour said...

Could not agree more with this post and it is equally true for Doctors as it is for hospitals. Who is "the best" cardiologist? Urologist? Dermatologist?
Patients ask friends and doctors they know for referrals. Do these people really know who is the best... Indeed not, a mythology exists here as well. Referrals are based on such things as visibility, reputation, amiability, affability, availability, sociability and longevity. Very rarely indeed are they based on ABILTY.

I recommend patients go to a specialty group practice and ask very specifically the nurses and assistants who work directly with all the doctors (in surgery if it concerns surgeons) which one they would send their sick relative to. Often it is not the esteemed head of the practice.

www.phones-news.ru said...

don't like hospitals. I think many people don't like them

T said...

Hi Paul,

(c.f. http://tchill.blogspot.com/2008/09/best-hospitals.html)

Denoting the "best" of any institution is tricky. It is especially tricky in medicine.

As a family physician I do inpatient work at a local community hospital. I did residency locally at a larger and more renowned academic hospital. The obstetrical portion of my residency I did at yet another local hospital, considered "inner-city". Which one is the "best"?

Medical care relies on doctors, nurses, lab personnel, secretaries, etc., working not only as individuals, but as a team. Hospital care depends upon another layer of non-medical personnel - an "extended" team that includes accountants, "care management" specialists, housekeepers, CEOs.... Because hospital care is so multifaceted, naming a "best" hospital requires very specific criteria and definitions. Do we grade mortality rate? Length of stay? Economic efficiency? Patient satisfaction? Usually it is a combined metric.

Patient opinions about hospitals in which I have worked vary widely. Of any given hospital, some patients sing praises, while others say they would never set foot in it. These opinions seem to be based mostly on personal or family experience, "medical mythology," news reports, etc., rather than data.

The community hospital at which I now work built a fancy "Women's Pavillion" for obstetrical services. "Medical mythology" (and advertising) rapidly sprung up that this was THE place to have a baby. When my wife and I had a baby last month, however, we delivered at the "inner city" hospital where I did residency.

This decision was based upon one main thought: that medical care, including hospital care, is only as good as the individuals giving it. Care management specialists may suggest and enforce protocol improvements, accountants may help determine equipment purchases, and administrators may direct hospital policy. Yet when it comes down to what happens to a patient, the thoughts and actions of individual doctors, nurses, and other caregivers determine healthcare quality.

The "inner city" hospital where my wife and I delivered is stigmatized because of patient demographic, location, etc. Yet the individual caregivers there handle numerous pregnancies, including many high risk and precipitous cases. And they handle them well. The physicians are very skilled, and not caught off guard by much. The nurses have a culture of empathetic care.

So which is the "best" hospital? Despite being physicians, my wife and I also wound up making our decision based on personal, albeit "insider," experience rather than "objective" data.

In 2007, Thompson-Reuters named the hospital in which I work today one of the nation's top 100 hospitals, and among the top twenty in the category of "Medium Community Hospitals". Do I feel good about this? Sure. Does part of me even want to believe that I played some small part since working there in late 2005? Sure. Do I believe the Thompson-Reuters criteria are important components of medical care? Sure. Yet I think it would be a big stretch to believe these criteria actually make any hospital the "best".


Allie said...

As a consumer (and therefor potential patient at a hospital), customer service is my number 1 priority.

I used to recommend the hospital in our med sized community over all others in the area, mostly based upon my friends and families experiences in said hospital.

However, when my husband was in a work related accident and requested to be transported to this hospital, he was treated with little respect as a patient and recieved little care.

For instance, I had to hold his blood-soaked bandage on his head because the nurses thought it better to chitchat in the lobby and speak to guy with a bad case of athlete's foot fungus. My husband had a six inch gash in his scalp going all the way to bone (which is rather gross may I add). I had blood dripping down my arms and my husband was in incredible pain. Now don't you think that it would have been better for the hospital to have given better customer service to this patient? No worries, I will never have false preconceptions that this hospital is better than any other hospital, and sadly I think that most hospital behave in this manner.

Although...I cant help but remember the ambulance even warning my husband not to go to this hospital in Lewisville, Texas. When even the paramedics know that this behavior happens at a paticular hospital--now that is scary!

barbara said...

Great post - not many people know how to find the best hospital and leave the decision up to their physicians. I believe the best hospital in your area can be located with a combination of quality and satisfaction data. Yes, most data are delayed, but they are still a good indicator of the quality you will receive, since it is very difficult to change them significantly in a short amount of time.

I also agree that word of mouth can be a very effective tool for identifying the best hospital. The problem is getting enough recommendations to make the information significant and to support the decision.

There are many websites that provide all of these pieces of information: quality, satisfaction and consumer ratings. One that I recommend is www.WhereToFindCare.com since it puts them all together in a format that you can rank. You can rate your experiences there...which I recommend some of the previous posters do. We can all learn from each other.

Avery said...

Paul, in your 9/2 post you stated:

...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....

What metric/s would give you this important information?

I would also like to call Allen's attention to the methodology of the U.S. News rankings. (He wrote on 9/3: "...For example, the US News annual ratings of doctors and hospitals, which if I remember correctly, is based on physician surveys that are subject to the 'mythology' noted in Paul's blog....")

In 12 of the 16 specialty rankings, reputation accounts for one-third of a hospital's score. The short version of the methodology is at http://health.usnews.com/articles/health/best-hospitals/2008/07/10/a-look-inside-the-hospital-rankings.html. There is a link to a much longer and more technical report.

I agree completely that ANY metric, or set of metrics, has major limitations. No rankings or ratings or other assessments can be truly authoritative. The U.S. News rankings are targeted not at all hospital patients or even at all hospital inpatients, but at a small subset of inpatients whose condition or planned procedure is very complex. I believe the rankings have merit viewed in this way.

Avery Comarow
Editor, "America's Best Hospitals"
U.S. News & World Report
Washington, D.C.

Paul Levy said...

Hi, Avery. Well, we actually publish the numbers of cases of preventable harm in our hospital, quarter by quarter, within a very short time of the end of each quarter. Check www.bidmc.harvard.edu.

To your point, I know of no other hospitals in this market who do that. Exactly one of my points.

I intentionally avoided the issue of your rankings or anyone else's, but, since you bring it up, in your ranking, I don't know why you ascribe value to the recommendations of doctors. They can be severely biased by their personal relationships with other doctors, often dating back to where they happened to get their training. To the extent that they might rely on clinical outcomes data to support their conclusions, perhaps you would be better off just basing your recommendations on that same data, rather than having it filtered in different ways by different doctors.