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Go to the Wrong Hospital and You’re 3 Times More Likely to Die
- mturmon 10y agoThey link to a heart surgery compilation by the Society of Thoracic Surgeons (http://www.sts.org/quality-research-patient-safety/sts-public-reporting-online http://www.sts.org/quality-research-patient-safety/sts-publi...) which is fun to explore. In metro LA, the top-tier hospitals (Cedars-Sinai, UCLA) have noticeably better outcomes than regular hospitals. The difference is like 98.7% of patients not dying versus 97.9% in a valve replacement ("AVR"). Flip it around and it's 1.3% versus 2.1% -- definitely noticeable. OTOH, UCSF (presumably top-tier, SF residents correct me if I'm mistaken) has 2.3% chance of dying. Maybe it's not a top-tier facility for AVR? And further, a small midwestern hospital in Hays, KS (pop. 21000) has a 3.6% chance of death. That's huge next to Cedars-Sinai at 1.3%!
- et2o 10y agoThese ratings are not great because they incentivize doctors not to take more complex cases. They claim to be risk-adjusted, but in reality you cannot adjust for all possible risk factors. Lots of things in medicine are very unique. There's very little that's more complex than human disease. As a referral center for other referral centers, additionally UCSF will be getting some of the most complicated cases in the world.
- mturmon 10y agoI agree that numbers can be gamed, and it's possible that private hospitals might be particularly motivated to do so. Indeed, probably these numbers don't make much sense for anyone outside a small medical community of insiders to assess. I'm not holding a torch for Cedars, but they are of similar stature for referrals AFAIK (not directly on-point, but indicative: https://www.cedars-sinai.edu/About-Us/News/News-Releases-2016/For-Third-Year-in-a-Row-Cedars-Sinai-Heart-Institute-Sets-Record-for-Most-Heart-Transplants-Performed-in-a-Year.aspx https://www.cedars-sinai.edu/About-Us/News/News-Releases-201...).
- et2o 10y agoThat's true, they are a high profile center in this field.
- ckluis 10y agoIn a previous life I worked for cardiac surgeons - one of them was on a board for the State of Florida to research outcomes and how to publish them without affecting which cases are taken. In the case of one example where NY started publishing outcomes the difficult cases switched to the Cleveland Clinic. The outcomes appearred to increase in NY and decrease at the Cleveland Clinic, but risk adjusted rates didn’t actually change for NY hospitals that transferred cases or for the Cleveland Clinic. This is absolutely something that happens and Cardiac Surgeons are all scientists to some degree. The results and risk adjustments are very well documented and they can determine them with a fair degree of accuracy. I’m not aware of the info for this particular case, but if they did risk adjust (the patient) it right - there are still a lot of other factors that determine quality of care (speed of delivery of service) and quantity of surgerys performed (if you don’t perform enough surgeries per year your quality suffers). Incidently, this is true for surgical staff (nurses) as well. If the surgeon travels to numerous to hospitals… the hospitals with the most surgeries performed will have better outcomes (after risk adjustment for them doing higher risk surgeries).
- et2o 10y agoIt's not that some surgeries are being shifted from one center to another, its that no one at all will do them, generally to the detriment of the patient.
- gozur88 10y agoSomeone will do them. There is a business model for surgeons who only take the sickest patients. Sure, in that case your numbers are worse, but that's the way you market yourself.
- nchammas 10y ago> These ratings are not great because they incentivize doctors not to take more complex cases. This reminds me of a scene in the recent Dr. Strange movie where the main character -- a neurosurgeon -- turns down a case because it had a high risk of failure and he didn't want to tarnish his perfect record. > They claim to be risk-adjusted, but in reality you cannot adjust for all possible risk factors. Lots of things in medicine are very unique. There's very little that's more complex than human disease. Isn't it better to approach the problem by improving how we do these risk assessments so that the risk-adjusted ratings are fair, as opposed to leaving patients in the dark about where to get the best care?
- et2o 10y agoIt's hard to just "improve the risk adjustments." The statistics aren't there. I agree patients shouldn't be left in the dark. The most important thing is getting the best care. There isn't an easy solution. However, I think the existing solution hurts patients (and I have seen these risk assessments first-hand numerous times).
- woliveirajr 10y agoIt reminds me of a relative who couldn't find a surgeon for his problem, because the first 2 thought he was a risky patient. Then the 3rd charged more. And thinking about it, I realized how many projects I jumped in while others jumped out because, you know, they were risky in not succeeding...
- MarkMc 10y agoYou seem to be saying that a hospital that doesn't want to take complex cases can more accurately adjust for risk factors than the people doing the study mentioned in the article. Is that right?
- madgar 10y agoNot the GP but I generally assume that a patient's actual doctors know more about that patient's physical body and how it will impact a procedure than some academics who are classifying/"coding" thousands of case files.
- aladoc99 10y agoSurgeons talk about a "look test" that refers to that certain something not captured by objective risk measures. A patient who doesn't look too bad on paper may look in person like they might not survive a haircut, let alone a valve replacement.
- MarkMc 10y agoThe database can store both objective and subjective risk measures. If there is good evidence that a 'look test' can improve risk assessment, lets get the referring doctor to perform a look test and store the result in the database. In that way the hospital will not have an edge over the risk-adjustment model used in the study. Edit: Many patients are already assessed by performance status [1] [1] https://en.wikipedia.org/wiki/Performance_status https://en.wikipedia.org/wiki/Performance_status
- deleted 10y ago[deleted]
- daveguy 10y agoYou also have to consider that the Hays, KS hospital, being a much smaller hospital, has a much smaller number of cases. The confidence interval around that is definitely larger as a result. Not sure how much larger, but likely enough to make the difference statistically insignificant (town pop is 21k, heart surgery # is likely very low). Put another way, a single death out of a small population of patients will have a larger impact on the statistics.
- tominous 10y agoAnother data point: 30-day mortality rates for high-risk acute heart patients are lower during the dates of national cardiology meetings, i.e. when the top doctors are away. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2038979 http://jamanetwork.com/journals/jamainternalmedicine/fullart...
- cbsmith 10y ago> Flip it around and it's 1.3% versus 2.1% -- definitely noticeable. Flip it back around and it is a 0.9% reduction in survival rates. ;-) I'm going to guess that hospitals aren't exactly the biggest factor influencing outcomes...
- toodlebunions 10y ago> The study did not disclose which hospitals had which results. Under the terms of the agreement to receive the data, the researchers agreed to keep the identities of the hospitals confidential. Well that's not too useful for the patient oh I mean "consumer"
- cmdrfred 10y agoIts only a free market in ways that are convenient for them.
- nickff 10y agoOutcomes vary widely by doctor/surgeon as well, but the medical profession has successfully resisted meaningful measurement of results for many years now.
- et2o 10y agoMost surgeons do not do enough cases over their entire careers to be meaningfully compared to their peers. There was a big paper about this recently. The ratings are a sham meant to instill false confidence.
- mrestko 10y agoCan you link the paper?
- et2o 10y agoI can't remember what journal it was published in and google isn't helping. I found this for hospital-level comparisons (these should be much more accurate due to far larger numbers): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250275/#!po=2.94118 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250275/#!po=2.... However: "Most commonly reported outcome measures have low reliability for differentiating hospital performance."
- monkmartinez 10y agoAgreed! There are shit doctors and great doctors, but they all have one thing in common... the Dr. preceding their name! They have resisted for good reason. I mean, when you have a bad day at the office, some code or deal or possibly something else breaks. When a surgeon has a bad day, it is not so simple and it is easy to forget they are human. I have worked countless full arrest codes in the field... countless. Some go a lot better than others, and some are even successful. Most codes are do not end well for the patient whose heart has stopped beating or the drive to breathe has stopped. I can't imagine having stats of the codes we work pushed in our face everyday. There are sooooo many variables that we don't control which would make the whole "measuring" endeavor meaningless to anyone that really cared. From the weight of the patient to the cleanliness of the house are all variables that may or may not matter. Good luck controlling for all that!
- dsfyu404ed 10y agoFWIW local demographics have a non-negligible effect on a hospital's specialty. The nearest hospital to a retirement community will get more practice at heart attacks and strokes and the one in the college town will be good at dealing with alcohol poisoning.
- gosub 10y agofrom the abstract: Risk-adjusted outcomes were calculated after adjusting for population factors, co-morbidities, and health system factors. Even after risk-adjustment, there exists large geographical variation in outcomes
- dzdt 10y agoThat means they adjust for things like that heart attacks in 80-year-olds are more likely fatal than in 40-year-olds, so a hospital serving mostly the former is expected to have a lower survival rate for heart attack patients. They are trying to measure differences in effectiveness for similar patients. GP gives a possible explanation for such a difference : the hospital probably gets good at the kinds of things it does a lot.
- calebm 10y agoOpens page, Looks for graphs, "Nope... no graphs...", Closes it
- randyrand 10y agoSo 4 options: 1. make the good hospitals worse 2. make the bad hospitals better 3. combination of 1 & 2 4. ignore Most people will want to choose 2 but inadvertently choose 3. When in reality we should have chosen 4.
- wyclif 10y agoNever get sick in the Philippines.
- pavel_lishin 10y agoCan you expand on that?
- sjf 10y agoIf it's anything like getting sick in India expect misdiagnosis, over-prescription of drugs and prescription of drugs that are banned in the US.
- ksjdj 10y agosamesies for cambodia n=1 tho
- BrandonM 10y agoI got 6 stitches in Cambodia for a major cut on my arm. No wait, seen by 3 medical professionals (including a doctor), in and out in 15 minutes. Total cost: $15. For me, that was a far better outcome than I would have received in the US for a similar condition. Of course, stitches are pretty well understood; I can't advocate for any other medical procedures in Cambodia.
- wyclif 10y agoYes, this is what I had in mind. In addition to all that, treatment by medical "professionals" who may be quacks and/or have qualifications granted by diploma mills.
- automatwon 10y agoWould saying "Go to the RIGHT hospital and you're 3 Times more likely to live?" be equivalent?
- trendia 10y agoNot really. Suppose 1 / 100 people die at a good hospital and 3 / 100 die at a bad hospital. If you go to a bad hospital, you're 3x more likely to die. But if you go to a good hospital, you're 99 / 97 or roughly 2% more likely to live.
- mjevans 10y agoThank you, that's almost crystal clear. Suppose 1 in 100 patients (for X) die at the best hospital and 3 in 100 die at the worst. Keeping percents the numbers are much less scare mongering. Best: 1% die, 99% live Worst: 3% die, 97% live Comparing the percents makes it sound much more significant "three times" (sounds like 300%, in an emotional sense).
- MarkMc 10y agoThis is so frustrating for me personally - I recently had to choose between several hospitals without knowing anything about the historical patient outcomes for each hospital. A hundred years ago a doctor named Ernest Codman suggested that hospitals should be rated by an "End Result System" [1] where paient outcomes were measured and compared, yet only now do we have the "first comprehensive study comparing how well individual hospitals treated a variety of medical conditions". And we still do not know exactly which hospital is best and which is worst. To me the best way to judge a hospital is blindingly obvious: For each patient at admission, estimate the chance he/she will be alive after 3 years. For example, a 65-year-old woman who is a smoker, is overweight and has stage 2 lung cancer might have a 25% chance of being alive in 3 years. Then compare the predicted outcome with the actual outcome. For example, say both Hospital A and Hospital B both admit 100 patients with 20% predicted chance of surviving 3 years. If after 3 years there are 30 such patients from Hospital A still alive but only 10 such patients from Hospital B, it would strongly indicate that Hospital A is better. We could look then at Hospital A for ways to improve Hospital B. What's so disheartening is that this process doesn't involve any special technology. It could have been implemented 100 years ago, albeit with less rigorous statistical methods. We spend a billion dollars on evaluating a drug which has a marginal, one-off benfit for a few hundred thousand people. But we ignore a process which is cheap and offers long-lasting benefits to millions of people. It seems that the medical establishment is too powerful in this case. [1] https://en.wikipedia.org/wiki/Ernest_Amory_Codman https://en.wikipedia.org/wiki/Ernest_Amory_Codman
- nradov 10y agoIt's not that simple, and it only seems blindingly obvious to you because you haven't actually worked in healthcare. The trouble with using survival or outcome ratings is that they effectively punish providers who take on the hardest, riskiest cases. We simply don't have enough accurate data. And many of the input variables aren't independent. The reality is that's it's impossible to accurately quantify all the different factors which potentially impact survival. So some providers find ways to game the system through metrics arbitrage. That said, it's still worthwhile to gather and use it for quality improvement. We just have to be careful to treat it with appropriate caveats and look at qualitative factors as well as quantified metrics.
- pseingatl 10y agoDo you think the Secret Service knows, for example, which hospital is best for gunshot victims? For stroke? For heart attacks? Of course they do. And yet, when Hillary collapsed at the 9/11 Memorial, they took her to no hospital, but to her daughter's apartment instead. Seems odd. Very odd.
- shawn-butler 10y agoI am struck by how similar this is to knowing how to choose a good school for your children.
- known 10y agoGo the Wrong "Doctor" and You're 3 Times More Likely to Die