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Few of us look forward
enthusiastically to a stay in a hospital. That's as it should be. Hospital
stays are not fun, and stays at even the very best hospitals pose significant
risks of infections and other mishaps.
But you'll be more comfortable
entering a hospital if you know that the hospital stay is really necessary,
that the hospital was selected carefully, and that you know how to deal
effectively with the hospital's staff. This guide is intended to help you find
that peace of mind.
For each of over 4,500 acute-care
hospitals nationwide, this guide gives you important information on what has
actually happened to each hospital's patients: estimates of the percent of
patients with various types of cases who have died or experienced adverse outcomes,
including complications.
For hospitals in major
metropolitan areas, we give you results from a major survey we conducted, in
which we gathered more than 140,000 ratings by physicians of hospitals in their
own communities: we tell you how each hospital was judged by those physicians.
Where data are available, we also
give you ratings from patients who have used the hospitals, results from
studies of data that examined how often hospitals performed the proper tests
and procedures for common cases, and other key facts that relate to quality.
Whatever hospital you choose, you'll want to get the best
care the hospital has to offer. What you get depends in part on how well you
are informed about what to expect during your stay—why you are there, what
drugs and procedures you're to be exposed to, how much attention you should get
from the nursing staff, etc. It also depends on how carefully you and your
family and friends keep an eye on what the staff is doing. This guide will help
you prepare for your stay and play a useful role in your care.
Finally, you'll find advice on
ways to help keep down the cost of your hospital stay. That's good for you and
good for the community.
To make the best possible choice of hospital, you must learn
as much as time allows about your case. This education is also essential for
you to answer two other critical questions: what is really wrong with you and
what is the best approach to treatment? In addition, whatever you learn will
help you play an active role later on in monitoring your care.
If a doctor recommends hospitalization, here are a
few questions for you to ask (often in this guide when we refer to "you," we
assume it is relatives or friends who will take responsibility for a sick
patient):
- What is the basis for the diagnosis? Are there other possible
explanations for your symptoms? Might it make sense to do further tests or
simply to wait awhile to get a surer diagnosis?
- What are the alternative ways of treating your problem? What are
the pros and cons of each—the chances of various outcomes in terms of your
lifestyle and ability to function?
- Can your problem be treated outside of a hospital? If there are
outpatient options, what are there pros and cons?
- Why are the particular hospital, and the particular doctor who
would care for you, good choices for your care?
- How complicated is the treatment you will get? Does it require
sophisticated medical staff or advanced equipment?
- What are the risks of complications? Will it be important to have
close monitoring and quick access to sophisticated medical staff and equipment
at all times?
- Is your required treatment one for which special training or
frequent experience is important? Are there certain hospitals or specialists
who have more skill, more experience, and higher success rates than others with
this treatment?
Up-to-date physicians will encourage you to ask such
questions, will offer answers, and will steer you to sources for further
research. Don't be concerned about insulting your physician by asking
questions. It helps to write out your questions as a reminder. If your doctor
is hard to talk with, take along a friend to help you press for answers.
A good physician will also encourage you to seek a second
opinion. Get one.
Get your second opinion from an entirely independent doctor.
If a surgeon who has recommended surgery refers you to another surgeon for a
second opinion, it will be difficult for the second doctor to recommend against
the advice (and the economic interests) of the first. To find a doctor to use
for a second opinion, you can ask friends and co-workers for recommendations,
contact a medical school, or ask for a referral from a well-regarded hospital.
To help you find a knowledgeable physician, our website
www.guidetotopdoctors.org identifies more than 23,000 top
physician specialists in 35 specialty fields who were most often recommended by
their peers in surveys we sent to nearly all the office-based physicians
practicing in major metropolitan areas. These physicians should be excellent
prospects for seeking a second opinion. If you read up on your type of
case—especially if it is of a type that is being actively researched at certain
medical centers—you may come upon names of leading specialists who might be
available for advice. When two doctors from whom you get opinions disagree or
are uncertain, you may want to seek additional opinions.
To keep down the cost and time required for a second
opinion, have your first doctor send copies of your medical records, x-rays,
and lab results to the second opinion doctor. This is standard procedure.
Medicare and most insurance plans will pay for second
opinions, and in some circumstances plans may pay for third opinions. In some
types of cases, insurance plans require second opinions.
Don't assume that because yours is a straightforward,
uncomplicated case there is nothing to learn and there are no decisions to be
made. In most cases, there are choices.
This point is brought home by studies done by Dartmouth
Medical School researchers and others, looking at variations in medical
practice in common types of cases across similar geographic areas. Some of the
early studies found, for example, that about 75 percent of the elderly men in
one Maine town had undergone prostate surgery, compared with fewer than 25
percent of men the same age in an adjacent town. Similar variations were found
in rates of hysterectomies, caesarean sections, and other common procedures.
Significantly, studies generally find no evidence that such medical practice
differences result in differences in the health status of the affected
populations.
The implication is that big
differences in the ways patients are treated result from differences in the
beliefs and customs of different physicians in different communities—possibly
influenced by financial considerations—the need to generate fees—and not
necessarily based on sound evidence of likely benefits to the patient. Even in
a common type of case, you can't assume that a physician's recommendation is
the best option for you.
Also, for many types of conditions, there are different
treatment options with different likelihoods of health improvement, discomfort,
harm to the patient, and even death; only you, when fully informed, can decide
which kinds of risks and benefits you weigh most heavily.
To learn about your case, you can use various online
resources. Some of the better ones are listed on this site under
Resources for Doing Your Own Medical Research. You can also
check one or more family health books available in most bookstores and public
libraries. Examples are the Harvard Medical School Family Health Guide,
the Mayo Clinic Family Health Book, The Merck Manual of Medical
Information, and the American College of Physicians Complete Home
Medical Guide.
To learn more about your case, you can take advantage of
much more extensive information available in libraries. At public libraries,
you can look at consumer-oriented newsletters and at medical textbooks. For
more in-depth information, you can use a medical school library. These
libraries will have both general textbooks and texts in specialty fields. They
will also have peer-reviewed medical journals, which will have articles on new
developments not yet reflected in textbooks. Contact the most conveniently
located medical school and ask what the rules are for public access.
An online search or a medical school library may also be
able to help you find support groups and organizations that regularly provide
information on your type of medical problem.
There are some websites that are
specifically oriented toward not only informing but also fostering patient
decision-making. The Ottawa Health Decision Centre http://decisionaid.ohri.ca is a catalog of links to decision guides, on topics ranging from "Should I have
surgery for my torn meniscus?" to "Should I have surgery to cure ulcerative
colitis?" The www.healthtalkonline.org website has videos of
patients telling about their choices and experiences with conditions ranging
from cervical cancer to heart failure.
As you learn more about your
treatment choices, you'll also learn about hospital choices. If yours is a case
that requires a high degree of specialization that is currently available only
at a few medical centers, you will want to use one of these centers for treatment.
If yours is a complicated, high-risk case, you will want to use a hospital with
sophisticated capabilities to deal with complications. If your case is
low-risk, you might choose to give substantial consideration to the
pleasantness of the staff and facility and its convenience to your home,
family, and friends.
Today's hospitals can shatter kidney stones with sound
waves; can look at tissues deep inside a patient's body without ever making a
cut; have machines to take over when organs fail; in short, can do what only a
few decades ago was beyond belief.
But hospitals remain today, as they always have been,
dangerous places. Where else do you allow someone to cut deep into your body,
inject potent chemicals into your veins, feed you strong drugs, and intervene
in your life in so many other ways? In the operation of such powerful forces,
at a time when you are sick and vulnerable, a single mistake can have
catastrophic consequences.
And mistakes do occur: missed diagnoses as a result of
inaccurate lab or x-ray results, administration of unprescribed medication, too
slow response in emergencies, infections passed among patients, heart attacks
caused by feeding the wrong solution into an IV hookup, operations on the wrong
patient or the wrong organ, unintended lacerations of healthy organs, patients
falling down or falling out of bed while under sedation, chokings from vomiting
of meals improperly given before surgery, and many more.
In fact, authoritative studies
have concluded that more than 40,000 patients per year, and possibly more than
90,000 per year, are killed in hospitals by preventable medical errors. That is
more than the number of deaths attributable each year to motor vehicle
accidents, breast cancer, or AIDS. And there are also many thousands of other
cases where hospital or physician negligence, while not causing death, slows
recovery or leads to short-term or long-term disability.
And those are the cases of negligence. There are countless
cases where doctors and hospitals are not negligent but do fail to provide the
best possible care—the kind of innovative, skilled, responsive care that might
give you better than average chances of a successful and speedy cure or
recovery.
A speech given years ago by Donald M. Berwick, a
well-known physician, Harvard Medical School professor, and chief executive of
the Institute for Healthcare Improvement, put a human face on problems that
have persisted through the years. He described—with his wife, Ann's,
permission—the experience he and Ann had endured during a year in which Ann had
six hospitalizations for a total of over 60 inpatient days in three
institutions:
"Let me first say that this painful summer and fall has left me
more impressed than I have ever been before with the good will, kindness,
generosity, commitment, and dignity of the people who work in health
care—almost all of them...
"Which makes it hard to tell the other side of the story. Put
very, very simply: the people work well by and large, but the system often does
not...
"[Medication errors] were not rare, they were the norm. The
neurologist in one admission told us in the morning, 'by no means should you be
getting anticholinergic agents,' and a medication with profound anticholinergic
side effects was given that afternoon. The attending neurologist in another
admission told us by phone that a crucial and potentially toxic drug should be
begun immediately. He said, 'time is of the essence.' That was on Thursday
morning at 10:00 a.m. The first dose was given 60 hours later... Colace was
discontinued by a physician's order on Day 1, and was nonetheless brought by
the nurse every single evening throughout a 14-day admission...
"A spinal tap was done for a crucial test for Lyme disease, but
the doctor collected too little fluid for the test, and the tap had to be
repeated. During a crucial phase of diagnosis, one doctor told us to hope that
the diagnosis would be of a certain disease, because that disease has a benign
course. The same evening, another doctor told us to hope for the opposite,
because that same disease is relentless—sometimes fatal... [Information was]
collected in disorganized, narrative formats, embedded in nursing notes and
daily forms... As a result, physicians often reached erroneous conclusions
about the past...
"On at least three occasions, Ann waited alone for over an
hour, cold, and frightened on a Gurney in the waiting area outside an MRI unit
in a sub-basement in the middle of the night... Ann's bedtime was 10:00 p.m.,
but her sleeping medication was often brought at 8:00 p.m. to accommodate
changes in nursing shifts... One place gave a sleeping pill at 3:00 a.m., and
then routinely woke Ann at 4:00 a.m. to take her blood pressure, which never
varied from normal."
These were just some of the examples Berwick reported.
Fortunately, by the time he delivered the speech, he could report that Ann's
condition had clearly begun to improve. But he and Ann, among the most
sophisticated of all possible patients, much more able than most to recognize
problems, had seen both the best and the worst of hospital care. Berwick has
used his and his wife's personal story as part of his life's work—to exhort his
professional colleagues to make the system work better. The rest of us can take
from it a warning that we must be vigilant in the selection of hospitals for
care, and we must be vigilant and actively involved in our care in whatever
hospital we use.
What you want for your care is a hospital that will keep
mistakes to a minimum and that will help you quickly improve your medical
condition and your ability to function; limit your discomfort; improve, or at
least maintain, your morale; and make your stay reasonably pleasant.
One of Berwick's conclusions about the hospitals in which
his wife received care was that "some were, in fact, much better than others."
That is a conclusion supported by the data in this guide and by much other
research. There are differences in how astute medical staffs are at spotting
changes in a patient's condition, how adept nursing staffs are at instilling
optimism in their patients, how good a facility's entire staff is at
maintaining sanitary conditions, and myriad other aspects of hospital
performance.
Certainly, if you are among the roughly one out of ten
Americans who will be admitted to a hospital this year, you will want to be
sure it's one of the best. But judging hospital quality is complex. Differences
in hospitals' death rates among heart attack patients, for example, might
simply mean that some hospitals get sicker, more frail patients; or that some
send their patients prematurely to nursing homes, where they die; or that some
are used by a few incompetent physicians who lose their patients despite the
best possible care from the hospitals' own staffs.
In this guide, we advise you on some facts to look for in
selecting a hospital and we suggest ways you can enhance the quality of care
you receive at whichever hospital you choose. The guide includes extensive
information on individual hospitals to help you choose a good one. We report
data on death rates and rates of other adverse outcomes, results of surveys in
which thousands of physicians rated hospitals, results of studies that looked
at whether or not hospitals performed the proper tests and procedures for
common cases, how hospitals were rated by their own patients, and other facts.
Unfortunately, these data do not give a clearcut way to sort
the best hospitals from the worst. All of the measures have some methodological
shortcomings, which are discussed at some length here. Some
hospitals look good on some measures and not on others. But this information
will enable you to find a few hospitals that look good across the board, and
will add to what you know about almost any hospital you might consider. The
information will help you have informed discussions about hospital choice with
your physician.
By making the data in this guide accessible to consumers, we
hope we have strengthened incentives for government, the hospital industry, and
health care researchers to continue to make improvements in methods for
comparing hospitals.
Much of the responsibility for choosing the right hospital
for you rests with your doctor. But you too must play an important role.
Your choice of hospital will generally be rather narrow if
your primary care doctor proposes admitting you to a hospital under his or her
own care. Most doctors have arranged privileges for themselves to admit
patients only at a few hospitals, or a single hospital.
But there's a good chance your primary care doctor will
refer you to a specialist who will be the one who arranges for your admission
to a hospital. You can consider hospital affiliation as one basis for selecting
the specialist you will use.
Your primary care doctor will probably favor a specialist
who practices at one of his or her own hospitals. These are usually the
specialists your doctor knows best. Also, your doctor may want to see you in
the hospital and work with the specialist. But the choices need not be limited
to your doctor's hospitals. You will want your primary care doctor to remain
involved in your case, to advise you and assure that all aspects of your care
are coordinated, but the doctor might not have to have privileges at the
hospital where you will be admitted in order to play this role. Discuss this
issue with your primary care doctor. Ask your doctor if he or she can arrange
to keep up-to-date on your care by communicating with the doctor or doctors who
will be responsible for you in the hospital.
All this presumes that you have a primary care doctor. But
there is another point at which comparison of hospitals is important: when you
are first choosing a doctor or health plan. There are two reasons to look for a
doctor or health plan that uses high-quality hospitals. First, this will
enhance your chances of being admitted to such a hospital in the future if the
need arises. Second, it enhances your chances that your doctor will be a
top-quality professional: good hospitals can be expected to attract good
physicians.
A comparison of hospitals is
especially important if you are considering a health maintenance organization
(HMO) or a preferred provider organization (PPO). If an HMO or PPO uses
high-quality hospitals, that suggests its overall medical care standards are
high.
Given the importance of choosing a
high-quality hospital, much of this guide is devoted to helping you make a good
selection. There will be no clear-cut answers, but we give you key information
to help you judge most of the hospitals in the U.S., and we advise on
additional information you can collect on your own.
Below is an overview, with a brief
description of the information this guide provides you on individual hospitals,
additional information you can gather on your own, and how you can use the
information to make a hospital choice. The section More About Our
Data is a more detailed description of our data on individual hospitals
and the strengths and weaknesses of these data.
We include in our Ratings Tables nearly
every short-term hospital for acute inpatient care in the U.S. except Veterans
and military hospitals. Below, we briefly describe the data in our tables.
- Percent of Doctors Who Rated the Hospital High. These are
the percentages of physicians who, in a large survey we conducted, rated each
hospital "very good" or "excellent" for "surgery on an adult in cases where the
risk of complications is high." We also show the number of doctors who rated each
hospital on this question.
- Risk-Adjusted Death Rates for All Selected Cases. These
are the percentages of each hospital's patients, for a three-year period, who
died within 30 days of the time they were admitted to the hospital. These rates
are adjusted—to the extent we were able—for differences in how sick and frail
each hospital's patients were. Rates are reported for selected, relatively
high-risk cases in three categories: medical cases, surgical cases, and a
combination of medical and surgical cases. We also show the number of cases
that were examined for each hospital for the analysis. This analysis is based
on data for Medicare patients.
- How Often the Hospital Did Proper Tests and Treatments (Best Practices) for Selected Cases. These are the percentages of instances in which each
hospital gave the test or treatment that would be called for by evidence-based
guidelines—for example, gave heart-attack patients aspirin upon arrival or gave
proper antibiotics to prevent surgical infections. The score shown is an aggregate
score calculated across four different types of care: heart attack, heart
failure, pneumonia, and surgical infection prevention. We also show the number
of observations in which each hospital's performance—either doing what was
called for or not—was checked. This analysis if based on data collected by the
federal government for its hospitalcompare.hhs.gov website.
- Percent of Patients Who Would Recommend the Hospital. These
are the percentages of patients who, in federally sponsored surveys of hospital
patients, said they "would definitely recommend" the hospital they had recently
used.
- For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition,
we give our checkmark (
 ) to
hospitals that rated high on an overall score we calculated across a range of
measures.
- Ratings for High-Risk Adult Surgery. These are the
percentages of physicians who, in a large survey we conducted, rated each hospital
"very good" or "excellent" for "surgery on an adult in cases where the risk of
complications is high." We also show the number of doctors who rated each
hospital on this question.
- Desirability scores from doctors. These are the results
when we asked each surveyed physician to name the two hospitals, from a list in
the physician's metropolitan area, that he or she would consider "most
desirable" and the two he or she would consider "least desirable" for several
different types of health care needs, from "uncomplicated delivery of a baby"
to "medical care for an adult in complex cases." We report for each hospital
for each type of case the percentage of its mentions that were favorable: that
is, the number of times physicians mentioned it as desirable as a percentage of
the total times physicians mentioned it as either desirable or undesirable.
- For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition,
we give our checkmark () to
hospitals that rated high on an overall score we calculated across a range of
measures.
- Risk-Adjusted Death Rates for All Selected Cases. These
are the percentages of each hospital's patients, for a three-year period, who
died within 30 days of the time they were admitted to the hospital. These rates
are adjusted—to the extent we were able—for differences in how sick and frail
each hospital's patients were. Rates are reported for selected, relatively
high-risk cases in three categories: medical cases, surgical cases, and a
combination of medical and surgical cases. We also show the number of cases
that were examined for each hospital for the analysis.
- Risk-Adjusted Death Rates for All Medical Cases. These
percentages show overall risk-adjusted death rates for the medical cases we
examined for our death-rate analysis. We also report the number of cases that
were examined for each hospital.
- Risk-Adjusted Death Rates for All Surgical Cases. These
percentages show overall risk-adjusted death rates for the surgical cases we
examined for our death-rate analysis. We also report the number of cases that
were examined for each hospital.
- Risk-Adjusted Adverse-Outcome Rates for All Selected Surgical
Cases. These are similar to the death rates except that adverse outcomes
include both deaths and complications (estimated by us) that resulted in
extended stays in the hospital.
- For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition,
we give our checkmark () to
hospitals that rated high on an overall score we calculated across a range of
measures.
- These tables show, for specific types of cases, whether or not
the hospital's death and adverse-outcomes rates were "Better" or "Worse"
than would be expected, given how sick and frail its patients were. To get a "Better" or "Worse,"
a hospital had to do enough better (or worse) than expected that we could be
quite confident that its better (or worse) performance was not just a matter of
luck. Where we list "Average" for hospitals, it simply means that we could not
be confident that their outcomes were different from what would be expected,
given how sick and frail their patients were. There are also many hospitals
that have "Insufficient data" on the table for many categories of cases. That
means these hospitals had a relatively small number of cases in these
categories—so small that we could not make a judgment on their outcomes.
- These are the percentages of instances
in which each hospital gave the test or treatment that would be called for by
evidence-based guidelines—for example, gave heart-attack patients aspirin upon
arrival or gave proper antibiotics to prevent surgical infections. The score
shown is an aggregate score calculated across four different types of care:
heart attack, heart failure, pneumonia, and surgical infection prevention. We
also show the number of observations in which each hospital's
performance—either doing what was called for or not—was checked.
- Heart Attack. Shows the percent of times the hospital
performed the proper tests and procedures for heart attack patients and the
number of observations.
- Heart Failure. Shows the percent of times the hospital
performed the proper tests and procedures for heart failure patients and the
number of observations.
- Pneumonia. Shows the percent of times the hospital
performed the proper tests and procedures for pneumonia patients and the number
of observations.
- Surgical Infection Prevention. Shows the percent of times
the hospital performed the proper tests and procedures for preventing surgical
infections and the number of observations.
- For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition,
we give our checkmark () to
hospitals that rated high on an overall score we calculated across a range of
measures.
These ratings come from federally sponsored surveys
of patients who had had recent hospital stays.
- Patients Would Recommend Hospital. The percentage of
patients who said they "would definitely recommend" the hospital they had
recently used.
- Overall Rating. Percent of patients who gave hospital an
overall rating of 9 or 10 (on a 0 to 10 scale).
- Communication with Doctors. Percent of patients who
reported doctors at hospital "always" communicated well.
- Communication with Nurses. Percent of patients who
reported nurses at hospital "always" communicated well.
- Receiving Help Quickly. Percent of patients who reported
they "always" received help as quickly as they wanted it.
- Medicines Always Explained. Percent of patients who reported
that hospital staff "always" explained about medicines before giving them.
- Pain Was Well Controlled. Percent of patients who reported
that their pain was "always" well controlled.
- Rooms Were Quiet. Percent of patients who reported that
the area around their room was "always" quiet at night.
- Rooms Were Clean. Percent of patients who reported that
their room and bathroom were "always" clean.
- Given Information About Recovery at Home. Percent of
patients who reported that they were given information about what to do during
their recovery at home.
- For each of these measures, we indicate with green type the most favorable scores and with red type the least favorable scores. In addition,
we give our checkmark () to
hospitals that rated high on an overall score we calculated across a range of
measures.
- Major Medical School Affiliation. This is simply one
indicator of the extent of each hospital's teaching programs for doctors.
- Progress Toward Meeting Patient Safety Goals. These data
come from The Leapfrog Group, an organization that tracks and
encourages hospitals' efforts to improve patient safety. We note with a "4" the
hospitals that have fully implemented Leapfrog's standards;
with a "3" hospitals that have made good progress in implementing
Leapfrog's standards; with a "2" hospitals that have made good
early stage efforts in implementing Leapfrog's standards; with
a "1" hospitals that are willing to report publicly but have not yet met
Leapfrog's early stage requirements; and with a "0" hospitals
that declined to respond to Leapfrog's efforts. Hospitals
scored with an "N" either had not yet been targeted by Leapfrog
or were not required to submit data for that measure.
Measures we report on are—
− Computerized
Prescription Order Entry System.
− ICU
Staffing.
− Safe
Practice Score.
− Adherence
to "Never Event" Policies.
- Notes.To view available notes for individual hospitals, see the footnotes at the bottom of the table.
The following is a more detailed discussion of our data and
how they should be interpreted.
To collect physicians' ratings of hospitals, we sent
questionnaires to about 340,000 physicians in the 53 largest metropolitan areas
of the U.S. and received about 18,000 responses. We surveyed virtually all of
the actively practicing, office-based physicians in these areas. For most
metropolitan areas, our survey was conducted during the spring and summer of
2008, but for some areas—the Boston, Chicago, Delaware Valley, San Francisco,
Seattle, Twin Cities, and Washington, DC, areas—our survey was conducted in the
summer and fall of 2006.
We gave each physician a list of
area hospitals and asked the physician to rate each "for surgery on an adult in
cases where the risk of complications is high." The physicians were asked to
use a five-point scale: "excellent," "very good," "good," "fair," or "poor,"
and simply to leave the form blank for hospitals for which they couldn't
answer.
Our Ratings Tables show for each hospital
the percentage, among the physicians who rated it, who said it was either "very
good" or "excellent." The tables also show the number of raters for each
hospital. We have not reported data on any hospital rated by fewer than 10
physicians. Some hospitals were rated "very good" or "excellent" by more than
70 percent of the physicians who rated them, while some got such favorable
ratings from fewer than 10 percent.
We believe these ratings are a useful indicator of
hospital quality, but you should keep several caveats in mind—
- In some cases, physicians may not have had a good basis for
judging hospitals. A physician who regularly visits a hospital can get a good
perspective on how responsive and thorough the nurses and other staff are, how
clean and organized the facility is, and other aspects of quality. But most
physicians don't see all parts of a hospital or see how it performs with all
types of cases. And many of the ratings were likely based on reputations among
the physicians' peers rather than direct experience.
- Physicians may have had biases—and possibly financial and
professional interests based on their hospital affiliations—that influenced
their ratings of specific hospitals.
- The types of physicians who responded to our survey might have
had different opinions of the hospitals than the types who chose not to
respond.
- Even if there was no consistent difference between the types of physicians who responded and the types who did
not, we know that for each hospital there is a mix of opinions among
physicians, and it is possible that some hospitals got relatively low (or high)
scores simply because they had bad (or good) luck in who happened to respond.
For example, for one hospital, our survey might have reached a few physicians
with the most negative opinions on a day when these physicians had time to
respond while physicians who would have given negative ratings of another
hospital were too busy to respond on the day the survey reached them.
Naturally, such bad or good luck is less likely to be the explanation for one
hospital's being rated higher than another if the number of raters was large or
the two hospitals' scores are very different. On our Ratings
Tables, we have used "Green" type to highlight the highest scores and we have marked
in "Red" type the lowest physician ratings scores.
We also asked the physicians to tell us which two
hospitals in the area were most desirable and which were least desirable for
various types of cases—
- Surgery on an adult in cases where the risk of complications is
high
- Surgery on an adult in cases where the risk of complications is
low
- Medical care for an adult in complex cases
- Surgery on a child in cases where the risk of complications is
high
- High-risk delivery of a baby
- Uncomplicated delivery of a baby
For each type of case, we counted the total number of
times each hospital was mentioned favorably and compared that number to the
total number of times it was mentioned at all (either favorably or
unfavorably). The Ratings Tables show, for each hospital for
the types of cases listed, the percentage of mentions that were favorable. For
example, if a hospital was mentioned for a given type of case as most desirable
by eight doctors and as least desirable by two doctors, that would give it a
score of 80 (eight favorable mentions divided by 10 total mentions equals 80
percent). On the Ratings Tables, we have not reported scores
for a type of case for any hospital that was mentioned fewer than five times,
and we have marked with an asterisk (*) any score that is based on fewer than
10 mentions.
This most desirable/least desirable approach to scoring
doesn't allow formal assessments of the statistical significance of
hospital-to-hospital differences. But hospitals that look good based on the
most desirable/least desirable approach tend also to look good when rated on
the five-point poor-to-excellent scale. Since we used both types of questions
to ask about "adult surgery in cases where the risk of complications is high,"
we can compare the results. Consider, for instance, hospitals that received at
least 10 most desirable/least desirable mentions and at least 25 ratings on the
poor-to-excellent scale; of those that scored in the top half based on most
desirable/least desirable mentions, 92 percent were also in the top half based
on their score on the poor-to-excellent scale.
You can, on a smaller scale, collect the same kind of
information that we collected from physicians. You can ask physicians you know
for their recommendations, and you can ask your friends to get the thoughts of
physicians they know.
In choosing a hospital, you will want to know how successful
the facilities you are considering have been in delivering good results for
other patients. The most important result is keeping patients alive.
On our Ratings Tables, we report
risk-adjusted death rates. These rates were adjusted in an effort to take into
account the fact that some hospitals treat a relatively high percentage of
sicker and frailer patients, who would have a relatively high risk of dying at
any hospital.
The adjusted death rates are based on analysis of records of
hospital stays of Medicare patients 65 or older admitted to hospitals in three
Federal Fiscal Years, from October 1, 2003, through September 30, 2006—over 40
million hospital admissions nationwide. This is the only available uniform,
nationwide data file of hospital cases. (The records for the year ending
September 30, 2006, are what are referred to as "provisional" records, but historically
there have been very few changes between the provisional record files and the
final record files.)
The hospitals submit records to Medicare to get reimbursed
for services rendered. Medicare adds one fact to the records submitted by the
hospitals—whether the patient died within a specified number of days after
hospital admission. Medicare gets this information on deaths, even on deaths
that occurred after a patient's discharge from the hospital, by using Social
Security records.
Our mortality rate analysis was conducted by Michael
Pine and Associates, a Chicago-based firm that is expert in
evaluating the clinical quality of hospitals.
The analysis began with the selection of a subset of cases.
We selected types of cases that are relatively common and that have substantial
death rates that might be affected by the quality of a hospital's care. The
cases included acute myocardial infarction (heart attack), obstructive
pulmonary disease, cerebrovascular accident (stroke), and seven other types of cases
in which patients were treated medically. They also included 11 types of
surgical cases, such as coronary artery bypass graft surgery, large bowel
surgery, and total hip replacement. The cases were selected from the Medicare
records based on detailed definitions using standard diagnosis and procedure
codes.
On Ratings Tables, you will see, for
example, a column showing "risk-adjusted death rate for all selected cases."
You will see that the death rates range from below nine percent to more than 13
percent. This difference suggests that, among similar patients with serious
medical problems or surgical procedures, those going into one of the
high-death-rate hospitals have a four-percentage-point higher chance of dying
than those going into one of the low-death-rate hospitals.
A four-percentage-point difference in chance of dying in a
few days is something that most people will be intently interested in avoiding.
To put this figure in perspective, consider a four-percentage-point difference
in death rates for a few days of stay in two different hotels—one hotel with a
zero-percent death rate and the other with a four-percent death rate among
visitors staying there for a few days. Such a difference would certainly be
headline news.
It is important to note that we did not look at all cases.
The average death rate across all hospitals for all the types of Medicare cases
we selected is higher than the death rate would be if we reported on all cases,
including low-risk cases, the hospitals treated. So hospitals are not as
dangerous overall as the death rates for our selected cases might suggest, but
the adjusted death rates we present are useful in comparing the hospitals for a
broad group of serious types of cases.
Adjusted death rates were calculated in several steps.
First, for each type of case, we calculated the actual death
rate for each hospital. We counted all deaths that occurred within 30 days of
admission, even if they occurred after the patient was discharged from the
hospital. Checking for this 30-day period eliminates the possibility that a
hospital might have relatively low death rates only because it discharges
patients to their homes, hospice care, or nursing homes when they are on the
verge of death.
We then calculated a "predicted"
death rate for each type of case for each hospital. The predicted death rate
tells what percent of the hospital's patients would have died if the hospital
were just as successful as the average of all U.S. hospitals in keeping similar
patients alive. The patient characteristics that were taken into account in
determining whether patients were similar were age, gender, the presence or
absence of selected principal and secondary diagnoses, and whether certain
surgical procedures were performed. For example, a hospital that had heart
attack patients who were mostly over age 85 with secondary diagnoses like
congestive heart failure, diabetes, and malnutrition, might have a considerably
higher predicted death rate for heart attack cases than a hospital whose heart
attack patients were mostly age 65 to 70 and had few other medical problems.
(More detail on the methods used by Michael Pine and Associates
to calculate predicted death and adverse outcome rates is included in this
technical report.)
Next, we used each hospital's predicted death rate and
actual death rate along with the national-average death rate to calculate an
"adjusted" death rate for the hospital. The simplest way to calculate an
adjusted rate is in two steps. First, we can calculate the ratio of the actual
rate to the predicted rate. If, for example, Hospital A has an actual death
rate of five percent but would be predicted to have a death rate of 10 percent
based on how sick and frail its patients are, then the ratio is 0.5 (five
percent divided by 10 percent). Second, we can multiply this ratio by the
national average death rate to get the adjusted death rate. If the national
average death rate were 12 percent, then the adjusted death rate for Hospital A
would be six percent (12 percent multiplied by the 0.5 ratio). In fact, we used
a more complicated formula (using odds ratios) for calculating adjusted rates,
but the result is very nearly the same.
For each hospital for each category of cases, we also
checked whether the difference between the actual death rate and the predicted
death rate was "statistically significant." For example, if the actual rate was
nine percent and the predicted death rate was 10 percent, what are the chances
that the one percentage point difference was the result of the hospital's
simply having had unusually good luck with its patients during the three-year
period we analyzed?
We know that some patients survive when the average
patient in a similar condition who experienced the same treatment would be
expected to die, and some die when the average similar patient given the same
treatment would be expected to survive. Since the difference in result can't be
explained, we call it good luck or bad luck. And any given hospital might have
a string of good luck or bad luck with its patients. But big differences
between actual and predicted death rates for large numbers of cases are not
likely to be the result of luck alone. For each hospital for each category of
cases on the Ratings Tables, we have used different color
typefaces for the adjusted death rate to indicate whether the difference
between the hospital's actual death rate and its predicted death rate was
"statistically significant":
- Green type—the hospital
did better than predicted, and there's less than one chance in 40 that this
better-than-predicted experience is just the result of good luck.
- Regular type—although the hospital may have done better or worse
than predicted, there's at least one chance in 20 that its better- or
worse-than-predicted experience is just the result of good or bad luck.
- Red type—the hospital did worse than predicted, and there's less than one chance in
40 that this worse-than-predicted experience is just the result of bad luck.
On the "Death & Adverse Outcome Rates—Overall" tab
of the Ratings Tables, we show adjusted death rates and
statistical significance for three categories of cases: all selected case types
(medical and surgical combined), all selected medical cases, and all selected
surgical cases.
On the tables under the "Death and Adverse-Outcome
Rates for Specific Medical and Surgical Cases" tab of the Ratings
Tables, we present death analysis results on those three categories of
cases and also on more specific categories of cases, such as heart attack,
stroke, pneumonia, and large bowel surgery. These tables present the data
differently from how they are presented for the "Overall" tables. Instead of
reporting adjusted death rates, we simply indicate whether the hospital's death
rate for each category of cases was statistically significantly better or worse
than predicted, given the hospital's mix of patients. We score the hospitals as
follows:
- Better—the hospital did
better than predicted, and there's less than one chance in 40 that this
better-than-predicted experience is just the result of good luck.
- Average—although the hospital may have done better or worse than
predicted, it's likely that its better- or worse-than-predicted experience is
the result of good or bad luck.
- Worse—the hospital did
worse than predicted, and there's less than one chance in 40 that this
worse-than-predicted experience is just the result of bad luck.
If a hospital's number of cases or predicted number of
deaths was too small, we reported neither adjusted death rates nor the
significance of the difference between actual and predicted death rates. For
such hospitals, the tables show "Insufficient data."
Let's look a little more fully at the strengths and
weaknesses of the death rate data. How valuable are they in choosing a hospital
for your care?
The data are helpful in predicting
a hospital's outcomes—especially among hospitals with a reasonably large number
of cases. We have found over the years that hospitals that have significantly
better-than-average adjusted death rates in one period are substantially more
likely than other hospitals to have significantly better-than-average death
rates in subsequent years.
But, while the data have predictive power, there is
much debate about the usefulness of such data for comparing hospitals. The
following are some limitations that are important to keep in mind when
considering the data on different hospitals—
- From the billing records submitted to Medicare by the hospitals
and used for our analysis, it is impossible to know for sure whether secondary
diagnoses existed when the patient entered the hospital or whether they
occurred during the hospital stay. In many cases, one can confidently make an
assumption about where a secondary condition started. Consider heart attack
cases. If the patient's record says the patient had diabetes as a secondary
diagnosis, we can be confident that the diabetes was there on admission. In
contrast, if the record says the patient had pneumonia, we can't tell whether
the patient came into the hospital with the pneumonia or acquired it in the
hospital. Medicare should, and soon will, have a flag on each patient record
for each secondary diagnosis indicating whether the problem was present at the
time of admission. Without knowing this, we can't know whether to give the
hospital credit for having more difficult cases if it has an unusually large
number of heart attack cases with pneumonia. We wouldn't want to give the
hospital such credit in our analysis if the hospital is causing the
pneumonia. Some states have for several years required hospitals to indicate
for each secondary diagnosis whether it was present upon admission to the
hospital, and in our analysis, Michael Pine and Associates used
data from state records to determine which secondary diagnoses were likely to
have been present at the time of admission.
This is an innovative approach. But when using this
approach or any other available approach, it is inevitable that some secondary
diagnoses will be miscoded as having been present at admission when in fact
they occurred in the hospital and others will be miscoded as complications that
occurred in the hospital, when in fact they were present at admission.
- Because of data limitations, various underlying characteristics
of patients could not be considered. Suppose, for example, you are looking at a
public hospital that caters to low-income, uninsured patients. There's a good
chance that the hospital's patients might have social problems—such as the
absence of emotionally supportive family members—that are not reported in the
data available for analysis but that might affect death rates within 30 days of
hospital admission.
- Within any one of the types of cases we looked at, patients may
have diseases at different stages of progression, with very different risks of
death. Some hospitals' pneumonia cases, for example, might include a
disproportionately large number of cases in which the disease was at an
advanced stage by the time the patient was admitted. The data we were working
with did not include information on laboratory or x-ray results, which would
make it possible to distinguish among patients on the basis of these findings.
Undetected differences in patient mix are especially likely when comparing
hospitals if one hospital is a regional referral center to which other
hospitals send their difficult cases.
- Cases were followed for only up to 30 days after admission.
Problems caused by some hospitals may not result in death until later than
that. (Longer follow-up periods, of course, have their own set of problems
since more time increases the chances of death from causes unrelated to the
hospital stay.)
- Some differences in death rates may result from differences in
community practices or in the availability of non-hospital facilities to care
for patients. In some communities, for example, patients in final stages of
emphysema (obstructive pulmonary disease) may be allowed to die in their homes
or in nursing facilities, while in other communities these patients may be
admitted to hospitals for their final few days.
- Some of the data for some hospitals may not be accurate. There
are, no doubt, many innocent errors when so many records are processed by
hospital coding staffs. In addition, it is likely that hospitals follow
different coding guidelines in describing diagnoses in the records they report
to Medicare in their efforts to get the highest allowable reimbursements for
the cost of care.
- Some of the data are incomplete. For example, the billing record
that is the source of the data has space for hospitals to list only eight
secondary diagnoses in addition to the principal diagnosis. If a patient had
nine or more secondary diagnoses, the adjustment process was not able to allow
for the secondary diagnoses in excess of eight.
- Time has elapsed since the period to which the data apply. The
Medicare records of hospital cases don't become immediately available to the
public or to researchers, and it took time for us to do our analyses.
- The data are for patients 65 or older. It is possible that
hospitals that perform well with that age group don't do so well with younger
patients.
- High or low hospital death rates may result from the quality of
treatment provided by specific doctors, not from the quality of the hospital's
performance. If a hospital does well because of specific doctors, that may do
you no good if you use a different doctor.
To use our data on death rates, first look for
categories of cases like yours on the "Specific Cases" tab. If you are looking
for a hospital to use for major bowel surgery, for example, look for hospitals
with death rates that were significantly Better
than predicted in that category.
If your case doesn't fit any of the categories on our table,
or if you are selecting a hospital in advance of the need (for example, as a
consideration in choosing a physician or HMO), look for a hospital with a
favorable score in the "all selected cases" category and possibly in several
other categories of cases of interest to you.
It is interesting to note that hospitals that had
significantly better-than-predicted mortality rates in the "all selected cases"
category also tended to get higher ratings than other hospitals from surveyed
physicians. As this figure shows, the hospitals that had
significantly better-than-predicted mortality rates were rated "very good" or
"excellent" on average for "surgery on an adult in cases where the risk of
complications is high" by 41 percent of surveyed physicians. Hospitals that had
significantly worse-than-predicted mortality rates got such favorable ratings
from substantially fewer surveyed physicians (only 29 percent).
Be sure to discuss the death rate data with your doctor. Ask
for any information he or she has that might explain an especially high or low
adjusted death rate. In addition, we recommend asking hospitals for their
comments on their death rates. Call the hospitals' public relations
departments.
The death rate information we have presented focuses only on
one bad outcome: death. But there are other bad outcomes. You don't want to
contract an infection in the hospital, have a bad reaction to a drug, fall out
of bed, or have any of many other types of complications even if you ultimately
survive. Some complications cause permanent disability or disfigurement; others
just make your hospital stay longer and more unpleasant. You want neither.
We would have liked to be able simply to report
risk-adjusted complication rates for the hospitals alongside the risk-adjusted
death rates. Because of the nature of the Medicare records, however, it's not
so straightforward. As mentioned above, the records Medicare gets from the
hospitals list secondary diagnoses but don't indicate whether these problems
started in the hospital or were present at the time of admission. It's obvious
that diabetes was not caused by the hospital, and it's very likely that an
infection in a surgical wound is a complication that occurred in the hospital.
But a secondary diagnosis of pneumonia might reflect a condition that occurred
in the hospital or one that existed at the time of admission. It is important
that Medicare moves forward quickly with a requirement that hospitals put a
flag on each secondary diagnosis as to whether it is an in-hospital
complication or was present at admission. But it will be a few years before we
have data coded that way. In addition, even with such a coding requirement, not
all complications would be coded, and there is a question whether hospitals
will accurately identify complications if doing so will hurt their scores in
billing or in hospital ratings systems.
To give you information that might alert you to high
complication rates, we took a roundabout approach. We looked for complications
only in surgical cases. Our assumption was that for most of the surgeries,
timing was discretionary, and patients would not generally be admitted to a
hospital for surgery if they currently had an infection or some other medical
problem that might be expected to go away if the surgery were simply delayed.
Using these cases, Michael Pine and Associates, which did the
analysis for us, developed a proxy indicator for complications in cases where
death did not occur within 30 days of hospital admission. The proxy indicator
is intended to highlight complications regardless of whether they are reported
as such in the hospital records. This proxy indicator looks for prolonged
hospital lengths of stay. Analyses of medical records have shown that a large
proportion of prolonged lengths of stay are associated with important
complications.
Here is a simplified explanation of how that analysis was
done. The analysis recognized that, for a given category of cases, a given
hospital will have varying lengths of stay, even after allowing for differences
in patients' characteristics. But after allowing for differences in patient
characteristics, most of this variation will be clustered around the hospital's
average length of stay for that category of cases. Cases in which the length of
stay is not within a hospital's predicted cluster are likely to involve
complications. For each category of cases for each hospital, the analysis
identified cases that had lengths of stay outside the predicted cluster of
lengths of stay. These were deemed to be prolonged lengths of stay. Such
prolonged lengths of stay, like deaths, might occur more often in hospitals
with especially sick or frail patients, so the analysis calculated a predicted
percentage of prolonged lengths of stay for each hospital based on the mix of
characteristics of the hospital's patients.
The predicted percentage of prolonged lengths of stay was
then combined with the predicted percentage of deaths to come up with a
predicted percentage of "adverse outcomes" for each hospital. At the same time,
the actual percentage of prolonged lengths of stay was combined with the actual
percentage of deaths to come up with an actual percentage of "adverse outcomes"
for each hospital. The predicted adverse outcome rate was compared to the
hospital's actual adverse outcome rate to calculate a ratio that was in turn
used to calculate a risk-adjusted adverse outcome rate. This was done by
following the same steps, described above, that were used in calculating a
risk-adjusted death rate from the actual, predicted, and all-hospital death
rates. The risk-adjusted adverse outcome rates for each hospital, which take
into account both deaths and prolonged lengths of stay, are shown on the "Death
& Adverse Outcome Rates—Overall" tab of the Ratings Tables
for all selected surgical cases.
On the tables under the "Death and Adverse-Outcome Rates for
Specific Medical and Surgical Cases" tab of the Ratings Tables,
we also report for each hospital whether its actual adverse outcomes rate is
significantly different from the predicted adverse outcomes rate in various
specific categories of cases.
It is important to keep in mind that most of the caveats set
out above with regard to adjusted death rates also apply to adjusted adverse
outcome rates. In addition, while the death rates measure directly something we
care about—death—the adverse outcome rates use a proxy—length of stay—as an
indicator of the thing we care about—complications.
Surprisingly, we found no substantial relationship between
adjusted death rates and adjusted adverse outcome rates (once we eliminated
deaths from the adverse outcome rates). While these two rates are measures of
different types of outcomes, one might expect that hospitals that are
relatively good at preventing complications would also be relatively good at
preventing deaths. But similar analyses done by others, also looking at
complications and deaths, have had similar findings. When we ranked hospitals,
we put weight on death rates rather than on adverse outcome rates, but both
types of rates appear on our Ratings Tables.
These scores are derived from data published at the federal
government's www.hospitalcompare.hhs.gov website.
The scores we report show the overall percent of instances
in which the hospital performed the proper tests or procedures for four common
case types. To calculate these scores, the federal government examined patient
records for each hospital and assessed how often hospitals gave recommended
tests or treatments known to get the best results for patients with certain medical
conditions or who had undergone certain surgical procedures. This analysis
examines, for example, how often hospitals gave heart-attack patients aspirin
upon arrival or how often hospitals gave proper antibiotics to prevent surgical
infections.
The federal data report on four different medical case
types, and for each indicate how often each hospital did what it should have
done according to a set of guidelines. The case types were: heart attack (seven
measures of care), heart failure (four measures), pneumonia (seven measures),
and surgical infection prevention (seven measures).
The score we show on our Ratings Tables for
"All Selected Cases" is an aggregate score calculated across all measures for
the four conditions. (In other words, we added up all of the instances where a
given hospital did the proper tests and/or treatments across all reported
measures, and then divided that total by the total number of times the hospital
had an opportunity to perform the proper tests and/or treatments.) We also show
the number of observations that were examined for each hospital for the
analysis.
One limitation in these data is that the recommended care
may not always be the best treatment for everyone. There may be specific
reasons why a patient should not receive a certain standard treatment. For
example, someone who has recently had a heart attack should be given aspirin as
soon as possible upon arrival at the hospital—but not, of course, if that
patient is allergic to aspirin. Unfortunately, the federally reported data
cannot always take into account patients who should not have received generally
recommended care.
On our Ratings Tables, we have used "Green" type to highlight the highest scores and
we have marked in "Red" type the lowest
scores.
Data for these measures shown on our Ratings
Tables are for the period from January through December 2007.
The ratings from patients shown in our Ratings
Tables come from federally sponsored surveys, using a standardized
questionnaire and survey procedure. The survey asked a random sample of
recently discharged patients about important aspects of their hospital
experience. The survey attempts to collect at least 300 completed surveys for
each hospital every year.
When using these data, keep in mind that the mix of patients
can differ from one hospital to the next, and these differences in patient mix
can affect a hospital's survey results. The analysis has tried to take into
account these differences so that survey results reported are what would be
expected for each hospital if all hospitals had a similar mix of patients, but
these adjustments might not completely ensure fair comparisons for all
hospitals.
Also, the content of several of the questions is to some
degree subjective, and you may have different critical standards than those of
the surveyed patients.
Interestingly, as this figure indicates,
hospitals that got relatively high ratings from the doctors we surveyed also
tended to get relatively high ratings from surveyed patients.
Hospitals are not required to participate in the survey of
patients, although most larger hospitals will get somewhat lower reimbursement
rates on their claims for Medicare patients if they do not participate. We
believe all hospitals should participate (with the possible exception of very
small hospitals that have too few patients to yield a meaningful sample of
patient survey responses.)
On our Ratings Tables, we have used "Green" type to highlight the highest scores and
we have marked in "Red" type the lowest
scores.
Data for patient surveys shown on our Ratings
Tables are for the period from January through December 2007.
Our Ratings Tables also shows which
hospitals had major affiliations with medical schools according to fall 2008
federal government records. An affiliation with a medical school generally
means that various doctors and medical students check patients' records and
interview the patients. That can result in your getting a variety of
perspectives brought to bear on your case. Also, doctors who are at the cutting
edge of research and practice tend to have at least some of their practice at
hospitals affiliated with medical schools. This means that the doctors
practicing at these hospitals tend to be exposed to the newest developments and
to have their ideas challenged by sophisticated colleagues. In addition,
hospitals affiliated with medical schools are likely to have advanced
diagnostic and treatment equipment.
On the other hand, hospitals affiliated with medical schools
are generally larger than average. The care may be relatively impersonal. And
it can be annoying to be bothered by a stream of students and trainees, all
with an academic—but often not very personal—interest in your case.
This figure shows the
relationship between major medical school affiliation and physician ratings. As
you can see, the hospitals with major medical school affiliations were rated
much higher than other hospitals by surveyed physicians. And as shown in
this figure, hospitals with major medical school affiliations
also tend to have slightly (but statistically significantly) better adjusted
mortality rates for all selected cases than other hospitals.
Many studies have concluded that, in some types of cases, hospitals
that handle large volumes of cases have better results than other
hospitals—that, in effect, practice makes perfect. Our tables don't report on
hospitals' volumes for specific types of cases, but you can ask your doctor or
the public information staffs of hospitals you are considering how many cases
like yours they handle each year. Your doctor may have to help you define your
case type in a precise enough way for the information to be meaningful.
At a very general level, we have
reported on our Ratings Tables the total number of Medicare
cases each hospital discharged over a three-year period in the selected medical
and surgical case types we used for our death rate analysis. This gives you a
rough indicator of hospital size. Interestingly, as this figure
shows, the larger hospitals (those with more cases in this total case category)
had somewhat lower adjusted death rates for "all selected [medical and
surgical] cases" than hospitals with lower total numbers of cases.
On our Ratings Tables, we indicate whether
hospitals have documented progress toward meeting several patient safety goals
set out and measured by the Leapfrog Group for Patient Safety.
The Leapfrog Group tracks and promotes advances in the safety,
quality, and affordability of health care by supporting informed healthcare
decisions by those who use and pay for health care, and by promoting high-value
health care through incentives and rewards.
One Leapfrog Group measure, included on the
Ratings Tables, is whether hospitals have documented that their
doctors use computerized systems to order prescription medicine.
Thousands of patients die each
year as a result of drug errors in hospitals. Substantial numbers of these
deaths could be avoided if doctors used Computerized Physician Order Entry
(CPOE) systems. With CPOE systems, doctors enter orders into a computer rather
than writing them down on paper, and the prescription can be automatically
checked against the patient's current information for potential mistakes or
problems. For example, before the doctor can complete the prescription order,
the computer checks to see if the new prescription might interact badly with
another drug the patient is taking, or if the patient has a known allergy to
it. This type of system also reduces mistakes that result from misreading a
doctor's handwriting. Studies show a computerized prescription system can
reduce serious medication mistakes by up to 88 percent.
In order to meet Leapfrog's CPOE
standard fully for public reporting, hospitals must complete a questionnaire,
affirmed in writing by the hospital's chief executive or his or her designated
agent, documenting that the hospital:
- Assures that physicians enter at least 75 percent of medication
orders via a computer system that includes prescribing-error prevention
software and
- Requires that physicians electronically document a reason for
overriding an intercepted apparent error prior to making such an override.
Soon Leapfrog intends to have in place
a testing system that hospitals will be expected to use to demonstrate that
their inpatient CPOE systems can alert physicians to at least 50 percent of
common, serious prescribing errors.
On our Ratings Tables, we indicate which level hospitals had achieved as of March 23, 2009 on Leapfrog's CPOE measure—
Fully implemented Leapfrog's recommended
safety practice. |
Good progress in implementing Leapfrog's
recommended safety practice. (The hospital has a functioning CPOE system in at
least one part of the hospital or is currently implementing CPOE or has a
written implementation strategy. Also, the hospital has a board-approved budget
for CPOE and is committed to fully implementing CPOE.) |
Good early stage effort in implementing
Leapfrog's recommended safety practice. (The hospital has
developed an action plan, has a board-approved budget for CPOE, and is
committed to fully implementing CPOE.) |
Willing to report publicly: does not yet meet
Leapfrog's criteria for a good early stage effort. (The
hospital responded to all Leapfrog survey questions, but does
not yet meet the criteria for a good early stage effort.) |
Did not submit this information. |
Hospital had not yet been targeted by
Leapfrog or was not required to respond to
Leapfrog's survey for the measure. |
Only 90 hospitals nationwide had full CPOE
implementation confirmed by Leapfrog as of March 23, 2009.
Leapfrog formally invites hospitals in specific regions across
the U.S. to participate. It is in these geographic areas that
Leapfrog employer and employer-coalition members have made a
voluntary commitment to encourage the hospitals in their communities to
participate in publicly reporting their progress toward meeting
Leapfrog's recommended quality and safety practices. All
hospitals in the U.S., however, are welcome to participate if they choose.
We have found that the hospitals that met
Leapfrog's full standards for computerized prescription systems
scored significantly better, compared to those that did not fully meet the
standard, on both mortality rates and ratings by physicians.
On our Ratings Tables, we also report
another measure fromThe Leapfrog Group—whether hospitals have
documented that they have intensive care units (ICUs) that are staffed by
intensive care specialists.
More than 2 million patients are admitted to urban hospital
intensive care units each year in the U.S. These are units where patients with
acutely life-threatening illnesses or injuries receive around-the-clock
specialized medical and nursing care, such as mechanical ventilation and
invasive cardiac monitoring. Mortality rates for patients admitted to ICUs average
10 to 20 percent in most hospitals, and approximately 200,000 patients die in
U.S. ICUs each year.
Unfortunately, evidence suggests that ICU quality
varies widely across hospitals. A growing body of scientific evidence suggests
that quality of care in hospital ICUs is strongly influenced by the extent to
which care in these units is provided by "intensivists." The Leapfrog
Group defines intensivists as:
- Board-certified physicians who are additionally certified in the
subspecialty of critical care medicine, or
- Physicians board-certified in emergency medicine who have
completed a critical care fellowship in a properly accredited program, or
- Physicians board-certified in Medicine,
Anesthesiology, Pediatrics, or Surgery who completed training prior to the availability
of subspecialty certification in critical care and who have provided at least
six weeks of full-time ICU care annually since 1987.
Staff organization in the ICU is also important. In
general, hospitals have either "open" or "closed" ICUs. In an open system,
patients receive care primarily from physicians with responsibilities outside
the ICU. Critical care specialists are often available to provide expertise on
a consultation basis. In a closed system, patients are cared for exclusively by
critical care specialists or teams that are closer on hand for both fine-tuning
routine care and dealing with emergencies.
The Leapfrog Group cites a recent literature
review finding that high-intensity staffing (ICUs where intensivists manage or
co-manage all patients) versus low-intensity staffing (where intensivists
manage or co-manage some or none of the patents) is associated with a
30-percent reduction in hospital mortality and a 40-percent reduction in ICU
mortality.
Hospitals that fully meet Leapfrog's
ICU Physician Staffing (IPS) standard have documented that they operate adult
and/or pediatric ICUs that are managed or co-managed by intensivists who:
- Are present during daytime hours and provide clinical care
exclusively in the ICU and
- When not present on site or via telemedicine, return pages at
least 95 percent of the time within five minutes and arrange for an
appropriately certified physician or physician extender to reach ICU patients
within five minutes.
On our Ratings Tables, we indicate
with number designations which level hospitals had achieved as of March 23,
2009 on Leapfrog's ICU Staffing measure. The number
designations correspond to the scoring system described above for
Leapfrog's CPOE measure.
We also report on our Ratings Tables
for each hospital its status with Leapfrog for its "Patient
Safety Score." This measure examines hospitals' progress toward implementing
procedures to reduce 13 common, preventable medical mistakes. These scores take
into account whether or not hospitals—
- Have leadership structures and systems in place to promote
patient safety;
- Invest in performance improvement;
- Have teamwork training and skill building programs to promote
patient safety;
- Identify and mitigate risks and hazards;
- Have nursing staff that meets patients needs;
- Provide timely clinical information for patients and caregivers;
- Have procedures in place to prevent mislabeled x-rays;
- Have available discharge summaries for follow-up care;
- Communicate well enough with patients so that patients can repeat
details of their condition and treatment;
- Place patient preferences prominently in their charts;
- Provide proper interventions for all patients on ventilators;
- Prevent catheter-related infections;
- Comply with CDC hand-washing guidelines;
- Update and review patient medication lists with new orders;
- Maintain safe processes for using anti-blood-clotting medication;
and,
- Have systems in place to assess and prevent blood clots.
On our Ratings Tables, we indicate
with number designations which level hospitals had achieved as of March 23,
2009 on Leapfrog's patient safety score measure. The designations correspond to the scoring system described above for Leapfrog's CPOE measure.
We report here for each hospital its status with
Leapfrog for "Managing Serious Errors." The Leapfrog
Group asks hospitals to agree to all of the standards listed below if a
"never event" occurs within their facility. The term "never event" refers to
mistakes that should never occur in a hospital, such as, surgery on the wrong
body part or a death due to contaminated drugs or devices.
- Hospital agrees to apologize to the patient and/or family
affected by the never event.
- Hospital agrees to report the event, within 10 days of becoming
aware of the event, to the Joint Commission on the Accreditation of Healthcare
Organizations, a state reporting program for medical errors, or another
independent patient safety organization.
- Hospital agrees to perform a root-cause analysis of the event
consistent with instructions given by the chosen patient safety reporting
agency.
- Hospital agrees to waive all costs directly related to a serious
reportable never event.
On our Ratings Tables, we indicate which level hospitals had achieved as of March 23, 2009 on Leapfrog's never event management measure. The designations correspond to the scoring system described above for Leapfrog's CPOE measure.
Using measures on our Ratings Tables, we
calculated an overall hospital score for each hospital. Those that got our top
scores got checkmarks ()
on the table. Our overall scores reflect the specific weighting and cutoffs we
applied to the measures. You might weight the measures differently and single
out different hospitals.
In addition to the information on our tables, there is
additional information you can gather on your own.
If you have a strong relationship with a physician who would
care for you during a hospital stay, you will want to be wary of making a
hospital selection that will force you to give up, or strain, that
relationship. This is especially true if your case is one—knee ligament
surgery, for instance—in which there is low risk of hospital-caused death or
serious complications, but surgeon-to-surgeon differences in outcome in terms
of your ability to function as you would like are substantial.
Before letting a physician relationship dictate choice of
hospital, check whether the physician you prefer can be flexible. If it is your
primary care physician whom you want involved in your case but you are going to
have surgery or some other treatment that will be managed by a specialist while
you are in the hospital, you might want to choose a specialist affiliated with
the hospital you would prefer. You can ask your primary care physician to
arrange to communicate regularly with that specialist.
Also, before choosing a hospital based on a physician
relationship, be sure the physician or physicians you are counting on will
actually be caring for you. Find out which doctor will be in charge of your
care in the hospital. Will it be your primary care doctor, a surgeon, or some
other doctor? Find out how often each doctor will be visiting you. If you have
arranged for surgery from a well-known surgeon, make sure that this is the
surgeon who will actually do the hands-on surgery. Some big name surgeons set
up and supervise surgery but leave it to their assistants to do most of the
work; if that is the plan, you might want to change surgeons.
Regardless of whether you currently have a strong
relationship with a physician, one way to judge hospitals is by checking
whether they have high-quality physicians affiliated with them. The best
physicians are not likely to send their patients to low-quality hospitals. If
there are physicians you know to be excellent, find out which hospitals they
use. Our Guide to Top Doctors website is a source of names of
top-quality doctors whose hospital affiliations you can check out.
You might want to consider whether
a hospital has special services, programs, and strengths of kinds that are not
addressed on our data tables. For example, if you are likely to need
rehabilitation services, you might want a hospital that has strong capabilities
in that field. You can ask your physician which hospitals have such special
capabilities. You can also check with your state or local hospital association.
You can learn a lot of important information about
hospitals by making your own visits or talking with other consumers who have
been patients in, or regularly visited, available facilities. The best way to
learn about a facility is to observe when visiting friends of loved ones (or
being a patient, of course), but you can also learn by calling the
administrator's office at any hospital you are considering and arranging a
tour. There's learn about—
- Check the rooms. Are they roomy enough? How noisy are they? Is
there privacy in patient beds and in bathrooms—from the hall and from the other
patient in semi-private rooms? Are private rooms available and at what cost?
Are the rooms clean and attractive? Are there windows with a pleasant view, and
can they be opened for fresh air? Is there good lighting? Is there an easily
accessible call button at bedside and in the bathroom? Are TV sets placed where
they can be easily viewed? Can headphones be arranged so that you and your roommate,
if you have one, can avoid disturbing one another? Is there air conditioning?
Can temperatures be controlled on a room-by-room basis?
- Check the halls. Are they clean? Are they free of foul smells?
Are they free of heavy smells of deodorizers that might be masking cleanliness
problems?
- Check the other patient areas. Are there pleasant sitting areas
and places where patients can walk close to their rooms? Can patients walk or
sit outside in a safe and convenient place on pleasant days? Are there a cafeteria,
newsstand, lobby, and other facilities that will make the hospital pleasant for
visitors?
- Ask for a list of hospital policies. Are the visiting hours
reasonable? What are the hours for receiving phone calls? Can children visit?
How much flexibility is there on mealtimes and bedtimes? Can arrangements be
made for a relative or close friend to sleep-in near the patient? In general,
do policies seem reasonable?
- Check the staff. Do nurses and other staff members seem
responsive to patient needs? Do they respond promptly when called? Do they take
the time to listen and answer questions? Are they gentle? Are they respectful?
Do they seem competent?
- Check the food. Does it seem fresh and attractive? Are fresh
fruits served, and are fresh vegetables not overcooked? Do hot meals arrive hot
and cold meals cold? Do patients who are not on physician-ordered diets have
any choice of meals? Can arrangements be made for vegetarian, kosher, or other
special diets?
- Check the social work services. What are the staff's capabilities
for arranging needed services after discharge? Do they follow through?
The data on the Ratings Tables in this
guide relate to serious, high-risk cases. Even in such cases, having pleasant
surroundings, good meals, and other comforts will be important to you, but
these features deserve special weight in low-risk cases. In all cases, it is
very important that family and friends can conveniently visit you. Visitors can
bolster your morale and thus speed your recovery. The presence of visitors puts
the hospital staff on notice that someone cares about you; that might make the
hospital staff more attentive also. In addition, having family or friends to
observe the care you are getting is critical. They can help you look out for
medication errors, gaps in staff followup, inattention to your pain, hospital
routines like middle of the night wakeups that are unnecessarily disruptive,
and many other care and service problems. And they can speak up on your behalf.
The information on individual hospitals reported in this
guide and gathered on your own will help you in selecting a hospital. We
strongly recommend that you discuss the data with a physician or physicians you
trust. This discussion should be a two-way street; your opinions, information,
and preferences matter. If your physician recommends a facility that you would
not have chosen, ask why. Keep in mind that physicians may have reasons for
hospital choice that are unrelated to your well-being. Your doctor might find
it more convenient to have all his or her patients in the same facility. Within
a managed care plan, there may be financial penalties for the doctor if the
doctor doesn't use specific hospitals. You at least deserve to have an
explanation of the reasons your doctor thinks a specific hospital is best for
you.
Regardless of which hospital you are admitted to, you and
your family or friends can do a lot to influence the quality of care you
receive. What matters most is your attitude. It is important that you feel
involved in, and responsible for, your own care—that you view the hospital and
staff only as the setting and the means to help you get well.
If there is time, a little care in getting ready for your hospital
stay will serve you well later on.
If you will be getting care from a surgeon or other
specialist, meet with this doctor. Get a full explanation of exactly what will
be done. Get an understanding of who will be doing your surgery and what role
assistants might play. Find out who will be caring for you as you recover after
surgery and after you leave the hospital. If you are not happy with the
answers, this would be the time to change doctors.
If you will be having surgery, try
to meet also with the anesthesiologist. It is better to have this meeting in
the more relaxed atmosphere of an office visit than to meet with the
anesthesiologist, in the typical way, for a few hurried minutes right before
the operation. Arranging an appointment in advance is not easy to do (and be
sure to confirm that your insurance will cover it), but it is worthwhile, given
the importance to your safety of his or her work. You can ask your surgeon to
give you the name of the anesthesiologist and to help you make an appointment.
When the anesthesiologist asks questions, be sure to give thorough
answers—about high blood pressure, heart problems, allergies, or other
conditions that might put you at risk when under anesthesia. Also, confirm that
the anesthesiologist will actually be present with you in the operating room,
not a subordinate.
If you might need blood transfusions in connection with
surgery, ask your surgeon whether autologous transfusion makes sense for
you—giving your own blood and having it stored for your own later use. You
might be able to give a unit a week for several weeks before surgery.
Decide whether you will want a private or semi-private room.
With a private room, you avoid any problems with roommates who might be noisy
or have annoying visitors. But sharing a room with someone else gives you a
little company, is likely to increase the frequency of nurse visits to your
room since there are two patients to visit, and gives you someone who might be
able to call for help for you in a crisis.
Think carefully about packing for the hospital. Be sure to
take a toilet kit with toothbrush, shampoo, deodorant, and other items just as
you would if you were going on a vacation. Also, bring along a clock, things to
read, and things to write with. And bring pajamas, a robe, and non-skid
slippers.
Don't bring a valuable watch or expensive jewelry. They
might get stolen. You will not be able to keep an eye on it all the
time—certainly not when you are in surgery or recovery. Don't bring more than a
few dollars in cash. Bringing a credit card. Bring a cell phone if you have
one; if not, bringing a phone card is a good idea if you will want to make call
out-of-area calls. You might want to bring a few pictures to keep you company
and possibly a few other items of sentimental value, but label anything you
bring with your full name and realize that you might lose it.
Check in advance with your doctor which of your regular
medications, including vitamin supplements, you will be continuing to take
while in the hospital. Bring a list of these medications, noting the dosage and
frequency. If you bring the actual medications, have your doctor mark in your
medical record that you are to take these medications and that the nurses are
to find a place to store them; be sure to label them clearly as yours. Bring
them in their original bottles with labels.
Make arrangements for where you will go and how you will be
cared for after discharge. You may not know in advance what condition you will
be in after release, but it is wise to talk with your doctor about the
possibilities and to make at least preliminary arrangements.
Learn as much about your condition as possible before going
to the hospital by talking to your doctor and doing research in libraries and
on the Web. Ask your doctor to tell you what treatment is recommended, what
alternatives are available, and the consequences of each. Find out what
medications, if any, you will be taking, what they look like, and any possible
side effects. If you and your doctor go over these things before you are in the
hospital, you will be better prepared to deal with each treatment step and less
likely to be surprised or feel pressured about making decisions.
During treatment, keep notes on the results of tests. Also
keep track of changes in medications or diet and their effects.
Write down questions you want to ask the doctor or the unit's
head nurse during his or her visit and record the answers.
By keeping track of these things, you will know more about
your condition and what to expect. You will also know enough to question the
arrival of an unexpected meal or a new pill. It may not be yours.
Simply as a part of being in the hospital, many people
become more passive and dependent than usual. Inactivity and concern about your
condition contribute to this; so does the typical hospital routine of frequent
interruptions and continual waiting—for meals, tests, visits from the doctor
and friends, and medication. To help you be yourself, try to personalize your
day and your surroundings by putting out a few personal (not valuable) items
from home, by wearing your own clothes where possible, by calling friends and
asking them to bring you snacks (provided you are not on a restricted diet), or
by doing some work or reading. If not disruptive to others or harmful to your
condition, these kinds of activities might help you resist becoming excessively
reliant on the hospital and staff—and will help to assure that staff members
regard you as a person, not just a case. We know one patient who purposely wore
bright red pajamas and did aerobic exercises every day just so she would not be
typed simply as "thyroid tumor in 302."
In general, do all you can for yourself. No one expects you
to jump out of bed hours after you come out of the operating room. But as you
and your doctor feel you are able, try to feed yourself, get out of bed by
yourself, and generally take on as much as you can of your own care. This is
therapeutic for you and will gain you the respect of the staff.
Be sure to express your appreciation for the good care you
receive. Nurses have a demanding job and, like everyone else, need a little
feedback. If one of your visitors can bring a gift or some flowers for the
nurses, rather than for you, that will be appreciated. Also, learn your nurses'
names and call them by name.
Given the high risks of infections, drug errors, and other
hospital mishaps, it is essential that you take steps to protect yourself. If
this means you are not the most agreeable patient, so be it. This is a matter
of life and death.
Hospital-caused infections are a major killer—and a major
cause of suffering, anxiety, and extended hospital stays. Making Health Care
Safer, a report issued by the U.S. Agency for Healthcare Research and
Quality, stated that such infections "occur in seven to 10 percent of
hospitalized patients and account for approximately 80,000 deaths per year in
the United States."
Most infections are the result of the spreading of "germs" from
patient to patient on the hands of physicians, nurses, and other hospital
workers. The best way to reduce this problem is very low-tech: the people who
touch you in the hospital just need to wash their hands. Numerous studies have
demonstrated that handwashing sharply reduces rates of patient infections.
Although this has been known for 150 years, hospital workers simply don't
always follow the basic rules of hygiene. Most healthcare workers understand
the importance of handwashing but simply don't do it consistently—and aren't
even aware of how poorly they are doing.
The solution for you? Ask every healthcare
worker—including your doctor—who will be having direct contact with you to wash
his or her hands before touching you, your food, your medications, or
equipment that will come into contact with you. Studies have found that one of
the most effective ways—better than training programs or rewards and
punishments—to get health care workers to wash their hands is for patients to
ask them to do so.
Washing hands with disinfectant soap and water is one
effective technique. But it takes 15 to 30 seconds to do it right; it takes
time for the hands to dry; and washing hands many times per day can be
irritating to the skin. A faster, less irritating, and equally effective
alternative is hygienic hand-wipes.
Take to the hospital with you a supply of sanitizing
hand-wipes, which you can buy in the drug store, and keep them in a prominent
place at your bedside. These alcohol-based hand-wipes generally have emollients
that make them easy on the skin.
You may feel awkward interfering in the health care workers'
routines. Overcome it. Be polite, but not passive. The stakes are too high.
Some hospitals have found that instructing patients at admission that the
patients should ask every healthcare worker to wash his or her hands is an
effective way to increase handwashing compliance. But hospitals don't typically
take this approach. You need to do it on your own. You can simply explain that
you are doing as you were told by a book you read.
Ask also about equipment that will come into contact with
you. That stethoscope should also be cleaned with a sanitizing wipe.
Contaminated catheters, infusion pumps, endoscopes, and bronchoscopes can also
be a problem, though one you will have a harder time monitoring.
If your roommate or the roommate's visitors show signs of
contagious illness, like sneezing or coughing, ask your doctor about changing
rooms.
Protect Yourself Against Drug Errors
The Institute of Medicine report, To Err Is Human,
highlighted the shocking frequency of medication errors in hospitals. The
Institute cited numerous studies to document the problem. For example, one
study of a 37-day period in a sophisticated urban hospital found 27 cases of
"injury resulting from a medical intervention related to a drug."
Hospitals could do, and long since should have done, much to
reduce this problem, including the introduction of Computerized Physician Order
Entry (CPOE) systems. But there is also a lot you can do to protect yourself.
The key is to have a written list of the
medications—including medications taken via IV hookup—you will be receiving,
why, how often, and what the proper dosage is. If a medication looks different
from what you have been getting, stop and ask the nurse about it. Maybe it is
just a generic-equivalent substitute, but maybe it is the wrong drug. Be sure
the hospital staff knows about all the medications you and your doctors have
agreed you will be taking.
Make notes of when you get medications. If you don't get one
on schedule, ask the nurse why not. You and the nurse can confirm the missed
dose by checking your chart.
If you have an unexpected reaction to a drug, bring it to
the attention of the nurse immediately. Some, but not all, of the types of reactions
to look out for are tightness in your chest, shortness of breath or trouble
breathing, pain, burning sensations, dizziness, confusion, numbness, or
itching.
Hospital patients are at substantial risk of falling, even
patients who are young and strong and would not normally be considered to be at
risk. You may be weak from illness or injury or from too much time in bed, or
you may be dizzy or confused from medications. Falls can cause hip fractures,
other types of fractures, concussions, or other injuries.
There are various precautions you can take to avoid
falling—
- Before getting out of bed sit still on the edge of the bed with
your feet dangling until you are sure you have your balance. If you still feel
at all unsteady, call a nurse or aide to help—and wait for the help.
- If you have been instructed not to get up without help, follow
that instruction.
- Keep your eyeglasses by the side of your bed. Be sure you can see
normally, that your vision is not suffering from side effects of treatment,
before trying to walk.
- Wear slippers that have non-skid soles and that will stay on your
feet. If there are wet spots on floors, ask someone to dry them before
proceeding.
- Make sure that furniture is not in your way. Before going to bed
at night, check that furniture is arranged so that it won't interfere with you
if you have to go to the bathroom.
- Take your time. Even a few days in the hospital can sap your
strength. Use a walker if that will help.
- Don't get out of bed until your bed is cranked down and never try
to climb over raised side rails. Ask a nurse or aide to fix your bed so that
you can get out.
When you first arrive in your
room, locate the call buttons at bedside and in the bathroom. Tell the nurses
that you want to test them, and do so.
When you use a call button, you should expect an immediate
response—at least by intercom—to find out how urgent your need is.
If you don't get a quick enough response, call again. If you
feel desperate, use your outside phone line to call the hospital and ask to be
connected to the nursing station that serves your room number. If that, too,
fails to get a response, call your doctor.
Expect at least the following from the nursing staff—
- Nurses should observe you every few hours if you are not
seriously ill—every few minutes if you are critically ill.
- They should spend time with you to ask about any changes in your
condition, any pain, any new complaints.
- They should call your doctor if an unexpected change occurs—or if
you are concerned enough that you think the doctor should know.
- There should be some continuity of the nursing staff—not a
constant daily turnover of new faces.
Wrong-site surgery—operating on the wrong body part—is the
kind of mishap that gets dramatic attention in the press. Fortunately, it is
not very common. Unfortunately, it is still too common.
A key measure to avoid such catastrophes is to mark the
surgery site with a permanent marker, during a preoperative visit, before the
day of the operation. Such marking has become standard procedure among
competent health care providers. For example, in 1998, the American Academy of
Orthopaedic Surgeons endorsed a surgical site identification program called
"Sign Your Site." Ask your surgeon what site-marking procedure he or she uses,
and then mark the site together while you are at the doctor's office.
Be sure the nursing staff knows about your conditions—what
you are in the hospital for and other conditions that might affect the care you
should receive. Hospitals are big places. Hospital workers care for dozens of
patients every day. One worker takes over when another worker goes home. A lot
of information can get lost in the shuffle; confusion can ensue. Computerized
medical records, if properly used, would help. But most hospitals are
shamefully backward in implementation of such systems, relying instead on the
same types of patient records they have used for many years. It is,
unfortunately, important for you, if you are able, to keep track of what is
going on and make sure the right information gets from one caregiver to
another.
First, make sure they know who you are. Make sure your
wristband is accurate. To help everyone keep things straight, use a piece of
posterboard to make a sign with your name, serious allergies, and chronic
medical conditions and post it at the head of your bed. Some hospitals actually
supply posters for this purpose.
Be particularly vigilant at shift changes—to be sure the new
folks know what went on, or didn't go on, on the previous shift. The sign-out
procedures used in most hospitals when a physician goes off duty to pass
information to the "cross-covering" physician who will take care of patients in
the interim is often informal and unstructured. Errors are more likely to occur
during the coverage period of the cross-covering physician than when the
regular physician is on duty.
Keep a log of what happens to you each day. If something
seems to have been missed, or if there is an attempt to repeat some test or
treatment that you think is unnecessary because it has already been done, ask
about it. Refer to your log and your medical record.
Eating right is important for you to feel right when you are
at home, so it's not surprising that it is also important when you are in a
hospital. Unfortunately, that is not always easy. The food often leaves a lot
to be desired. If the food is not as hot or as cold as it should be, ask the
staff if that can be improved. If you find it just too unpleasant to eat, ask
your doctor to authorize you to get food from the outside and ask friends to
bring meals to you. Ask to have a small space arranged for you to store your
food in a hospital refrigerator. Be sure to label it.
If you routinely take vitamin supplements, get your doctor's
permission to take them in the hospital. Even if you don't take such
supplements regularly, they might make sense for you in the hospital since your
other nutritional intake may be deficient. Ask your doctor to arrange for your
vitamins to be properly labeled, stored, and dispensed by the nursing staff.
Ask to see a hospital dietician if you have problems with
food. Eat well, but be sure to follow orders about not eating before surgery.
It is important to your recovery that you be as comfortable
and happy as possible. If your roommate or the roommate's visitors are too
noisy, discuss it with your roommate. If that doesn't work, or if something
your roommate can't control like incessant coughing is making it very difficult
for you to relax or sleep, ask to have your room changed. If there is too much
noise in the hall, ask what can be done about that. Another possible solution
to noise problems is a radio, or a tape or CD player, with headphones.
Negotiate about schedule. If the staff routinely wakes you
up three times in the middle of the night, ask whether all those disturbances
are needed. See if you can take the medication or have the readings taken right
before bedtime or right after you wake up. If you are normally a late sleeper,
see if your normal schedule can be accommodated. If you don't want sleeping
pills, ask not to be given them.
If you want someone to sleep-in with you, ask for that to be
arranged. A comfortable chair should be arranged, and many hospitals will
provide cots.
You have a right—based on law and on medical ethics—to be
treated only after giving your informed consent. Before surgery, you will be
asked to sign a consent form. In the absence of consent, a surgeon's cutting
you open with a knife would be deemed negligence in some states, battery in
others. Yet studies have found that substantial percentages of patients do not
fully understand what their physicians have described about a procedure, and
many would like more explanation.
If you don't understand the risks, the benefits, the
alternatives, and other important aspects of a procedure, ask for more
information. Do this even if you have already signed a consent form. It is not
too late to change your mind right up until the procedure begins. This applies
not only to surgery, but also to radiology procedures, drug treatments, blood
transfusions, and other procedures that may pose risks to you.
You may be offered a chance to participate in a clinical
trial. A clinical trial is research in which the use of new drugs or medical
devices is tested in humans. The purpose of such trials is to learn whether new
treatments will benefit future patients.
Although the new treatment being tested might be better than
alternative treatments, it might be worse. Also, if you participate in a trial,
you might be assigned to the "control" group that gets a standard treatment
rather than the new treatment. (In cases of life-threatening disease, control
groups virtually always get a treatment that has been judged to have some
value, not just no treatment at all.) There is some evidence that patients who
have participated in trials have survived longer than patients who chose to get
treatment outside a trial. An explanation for such a difference might be that
patients in a trial may receive closer medical attention and more follow-up
visits than patients who are not in a trial.
A very valuable resource to help you make a decision
about participation in a clinical trial is Should I Enter a Clinical Trial?,
a guide prepared by ECRI, a nonprofit health services research organization.
The guide is available at www.ecri.org. Drawing on the guide,
we list below several types of information you will want to get to help you
decide whether to participate in a clinical trial—
- A summary of results from previous trials that led to this trial.
- The purpose of the new research—what it is trying to achieve.
- How long the trial will last for you if you remain in it to the
end.
- A detailed description of each test and treatment that will be
given according to the trial plan.
- The timing and the location of those tests and treatments and how
they are scheduled for you.
- Identification of any procedures that are experimental.
- A description of any reasonably foreseeable risks or discomforts
to you (for example, pain or minor and major side effects) from any test or
treatment that will be given.
- A description of any possible benefits to you or to others.
- A description of any alternative procedures or courses of
treatment that might be advantageous to you.
- A statement that participation is voluntary and that you may
refuse or discontinue participation at any time without penalty or loss of
benefits.
- A statement that significant new findings that may relate to your
willingness to participate.
- An itemization of any costs to you as a result of participation.
- A description of anticipated circumstances
under which the investigator may terminate your participation without regard to
your consent.
- A description of the consequences of your decision to withdraw,
if you decide to do so, and the procedures for withdrawal.
- The approximate number of participants involved in the study.
- A full disclosure of any financial interests the participating
researchers and institutions have in the research.
- Travel and lodging information for you and loved ones
accompanying you.
- A description of support that you might require from family and
friends for daily activities or daily needs while in the trial.
- A statement describing the extent to which confidentiality of
your records will be maintained.
- An explanation of whether any compensation and/or medical
treatments are available if injury occurs from treatment in the trial and, if
so, what they are and who will provide them.
- Information on whom to contact with questions about the trial and
your rights.
- Information on whom to contact in the event of a research-related
injury.
Nearly half of all surgery patients do not receive
adequate pain relief. The practice of delaying or withholding pain relief
medications due to fear of masking symptoms is widespread. Many patients
mistakenly worry that taking pain medication will lead to addiction.
Inappropriate treatment of pain results from poor understanding and skills of
providers and inadequate patient education. The American Pain
Foundation (APF), an organization devoted to educating consumers about
pain, wants consumers to have the following facts about pain, whether
in-hospital or elsewhere—
- Pain is not something you "just have to live with."
Treatments are available to relieve or lessen most pain. If untreated, pain can
make other health problems worse, slow recovery, and interfere with healing.
Get help right away, and don't let anyone suggest that your pain is simply "in
your head."
- Not all doctors know how to treat pain. Your doctor should
give the same attention to your pain as to any other health problems. But many
doctors have had little training in pain care. If your doctor is unable to deal
with your pain effectively, ask the doctor to consult with a specialist, or
consider switching doctors.
- Pain medications rarely cause addiction. Morphine and
similar pain medications, called opioids, can be highly effective for certain
conditions. Unless you have a history of substance abuse, there is little risk
of addiction when these medications are properly prescribed by a doctor and
taken as directed. Physical dependence—which is not to be confused with
addiction—occurs in the form of withdrawal symptoms if you stop taking these
medications suddenly. This usually is not a problem if you go off your
medications gradually.
- Most side effects from opioid pain medications can be managed.
Nausea, drowsiness, itching, and most other side effects caused by morphine and
similar opioid medications usually last only a few days. Constipation from
these medications can usually be managed with laxatives, adequate fluid intake,
and attention to diet. Ask your doctor to suggest ways that are best for you.
- If you act quickly when pain starts, you can often prevent it
from getting worse. Take your medications when you first begin to
experience pain. If your pain does get worse, talk with your doctor. Your
doctor may safely prescribe higher doses or change the prescription. Non-drug
therapies such as relaxation training and others can also help give you relief.
The APF has issued a pain care bill
of rights. Although these are not legal rights, they are standards that you
should expect to have observed. According to the APF, you have—
- The right to have your report of pain taken seriously and to be
treated with dignity and respect by doctors, nurses, pharmacists and other
healthcare professionals.
- The right to have your pain thoroughly assessed and promptly
treated.
- The right to be informed by your doctor about what may be causing
your pain, possible treatments, and the benefits, risks, and costs of each.
- The right to participate actively in decisions about how to
manage your pain.
- The right to have your pain reassessed regularly and your
treatment adjusted if your pain has not been eased.
- The right to be referred to a pain specialist if your pain
persists.
- The right to get clear and prompt answers to your questions, take
time to make decisions, and refuse a particular type of treatment if you
choose.
Remember, you have a role here. You must communicate
about your pain to your doctors and nurses.
At some point, patients, their families, and friends may
have to decide whether to extend life-sustaining treatment with measures such
as resuscitation, endotracheal intubation, feeding tubes, and administration of
IV fluids. If you want your end-of-life wishes honored, you will need to have
discussions with your family or other representatives and your physician in
advance. Good communication at the end of life can also help patients achieve
closure and meaning in the final days of their life.
In 1990, the Federal Patient
Self-Determination Act was passed by Congress to encourage competent adults to
complete advance directives. The act requires hospitals, nursing homes, health
maintenance organizations, and hospices that participate in Medicare and
Medicaid to ask if patients have advance directives, to provide information
about advance directives, and to incorporate advance directives into the
medical record.
Advance directives are any expression by a patient
intended to guide care, should the patient lose his or her medical
decision-making capacity. Although both oral and written statements are valid,
the added effort required to complete written statements gives them greater
weight. In addition to their use when patients lose competence, advance
directives also help patients consider the type of care they would want in the
future, even if they retain decision-making capacity. Advance directives have
legal validity in almost every state.
There are two principal forms of written advance directives:
living wills and durable powers of attorney for healthcare. A living will
is a document that allows you to indicate the interventions you would want if
you were terminally ill, comatose with no reasonable hope of regaining
consciousness, or in a persistent vegetative state with no reasonable hope of
regaining significant cognitive function. A durable power of attorney for
healthcare is a more comprehensive document that allows you to appoint a
person as a proxy to make healthcare decisions for you should you lose
decision-making capacity.
Unfortunately, the potential for advance directives to guide
patient care is often not realized. Many patients don't complete such
directives, and often the directives are not available or adequately
communicated at the time end-of-life decisions must be made. Even when a
written advance directive document is prepared, it may not meet its objective.
One study found that only 12 percent of patients with an advance directive had
talked with a physician when completing the document and only 25 percent of
physicians were aware of their patients' advance directives. One study that
surveyed elders in community settings found that 81 percent desired to discuss
their preferences with their physicians if they were terminally ill, but only
11 percent had done so. In one survey of 200 patients, only 18 percent had
filled out an advance directive and of these, 50 percent had secured the only
copy in a safe deposit box.
Copies of advance directives often are not transferred from
nursing homes to hospitals on admission. One study found that physicians
documented advance directives or discussions with appointed proxies about
treatment decisions in only 11 percent of admission notes. While 90 percent of
Americans say they want to die at home, four out of five die in a hospital or
other healthcare facility.
If you wish to have control over your own end-of-life
decisions, you will need to discuss your preferences with your family and
physician, complete the documentation, and make sure, on your own or through a
representative, that the documentation is included in your medical record at
hospitals or other care facilities you enter.
Before it is time to leave the
hospital, be sure you have a realistic plan for your care. Will you be able to
care for yourself at home? Will you be able to get along with the help of an
available family member? Will you need a visiting nurse or aide? Meals On
Wheels? A nursing home? Make contact early, even before you enter a hospital if
possible, with a hospital social worker and with other community social service
agencies you are familiar with.
You will also need to make sure that there is a plan for
your medical care and management by a physician after you leave the hospital.
Will you turn to your primary care doctor or to a specialist who treated you in
the hospital? If a doctor other than the doctor who managed your care in the
hospital will be responsible, you will need to take steps to ensure that the
doctor who will be taking over has full information about you and your case
right away.
That kind of information is supposed to be contained in a
well-organized and thorough "discharge summary," which is supposed to be
communicated promptly to the doctor who will be caring for you. Unfortunately,
it doesn't always work that way.
Discharge summaries often are in a relatively unstructured,
narrative format that invites inaccuracies. In addition, there can be
significant delays transmitting discharge summaries to the doctors who need
them.
In one study examining the
effectiveness of inpatient follow-up care, nearly ten percent of discharged
patients experienced worsening of symptoms or functional capacity as a result
of an inadequately managed discharge process. Another study demonstrated that
patients may be less likely to be readmitted to the hospital if their primary
care provider receives a discharge summary. Yet one study found that only 34
percent of patients had a discharge summary sent to their outpatient care
provider.
Be active in planning the care you will receive after
discharge. Before leaving the hospital, ask your doctor when a discharge
summary will be prepared, to whom it will be sent, and how it will be sent. Ask
that a copy be sent to you. Then keep track of whether you get one and check
with your outpatient care provider to be sure that provider's copy arrived.
If you feel you are not being treated with the proper
respect or care, talk with the staff concerned. If that fails, talk with the
nurse who works on the floor most regularly or with the head nurse on the
floor. You can also check whether the hospital has a patient representative or
ombudsman department. You can call a patient representative to talk about
anything from cold food to rude staff. This person is charged with taking the
problem to the responsible department and checking back with you to ensure that
the problem is corrected.
To help you insist on the care you deserve, it is useful to
know your rights as a patient. Every hospital should have a statement of
patient rights. You might ask for a copy of this statement at the time of
admission or before. It should cover such matters as the right to informed
consent and participation in your medical care, the right to privacy during
physical examination, and the right to refuse to participate in any hospital
research experiments.
If you consider a complaint serious enough—you believe your
health is in jeopardy or the quality of care is simply very bad—talk with your
doctor about having you transferred to another unit of the hospital or another
hospital, or just sending you home. The doctor should recognize that your
tension or unhappiness is not making you feel any better, and should be willing
to try something else.
Because hospitals are paid by the case by Medicare and in a
similar fashion by some other insurance plans, a hospital may come out better
financially by discharging patients prematurely. Don't let this happen to you.
First, tell your doctor that you don't feel well enough to go home. If he or
she can't or won't stop the discharge process and if you are on Medicare, the
hospital is required to give you a written description of an appeal procedure.
During your appeal, which usually takes a day or two, you can stay in the
hospital.
Most consumers care much more about a hospital's quality
than about its prices. That's because under many insurance policies, your
hospital bills will be paid in full even at the most expensive of hospitals.
But if your policy is less
generous—for example, requiring you to pay 20 percent of hospital costs—your
share of the differences in hospitals' charges can be significant—amounting to
thousands of dollars in some cases.
You can call hospitals to inquire about charges for a
private room or semi-private room and other basic services, and you can ask
about typical charges for your type of case. Also, check whether an agency in
your state regularly publishes comparisons of charges.
Whatever hospital you choose, there are various ways
to keep costs down. For example—
- Ask your doctor if you can have any needed tests—complete blood
count, urinalysis, etc.—done by an outside lab or as a hospital outpatient
before you are admitted to a hospital. You save by finding a less expensive lab
and by avoiding a day or more in the hospital. Also, check whether every test
the hospital wants to give you at entry is necessary and has been ordered by
your doctor. Your health insurance may not reimburse for tests routinely done
on admission unless specifically ordered.
- Ask your doctor if a hospital is the only place where your
treatment can be done. Perhaps several visits to a hospital or a clinic as an
outpatient will do just as well. If surgery is planned, check whether it is one
of the many procedures now being performed on an outpatient basis.
- Check in late and check out early. Hospitals work like hotels;
there is a time when the admission day begins and ends. Find out when it is. If
you can come in the same day as your procedure, you will not have to pay to sit
around. Short hospital stays are becoming more common. Ask your doctor if you
can go home as soon as you feel like it. Many people feel better resting at
home anyway.
- If your recuperation is likely to be long and you still require
nursing assistance, find out about home health services. Care in your home is
often much less expensive than prolonged hospital care, and may be more
convenient for your family. Your doctor or the hospital's patient
representative or social services department can help you get care at home.
Medicare and most insurance plans will cover some portion of the costs of this
kind of care if you have been in the hospital and the doctor recommends it.
- If you need blood transfusions, find out whether you can be your
own donor. If surgery is planned several weeks away, you may be able to give a
few units, which will replace themselves before the surgery. Find out if you
can donate for yourself or have friends and family donate for you.
- If your health insurance plan requires that you get authorization
from it before hospital admission in non-emergency cases and shortly after
admission in emergency cases, be sure to get these authorizations so you won't
be stuck with the bill. Also, be sure to find out whether a second opinion is
required before admission.
- Check your bill. Be sure you aren't being charged by a hospital
for more days than you were there. Also, check that you're only charged for
medications you actually received and for tests and x-rays that actually took
place. If a planned series of tests was canceled, be sure the charges didn't
make it onto your bill.
- Don't pay twice. If a hospital's staff does a test or x-ray
improperly or misplaces the results, be sure you are not billed for the retests.
You can find an enormous amount of medical information online. Several useful sites include the following:
Healthfinder
A free gateway to reliable consumer health and human services information developed by the U.S. Department of Health and Human Services.
Mayo Clinic
General-information website with Mayo's advice and information, including such features as "Diseases and Conditions A-Z," "Condition Centers," "Healthy Living," and "Health Tools."
MedlinePlus
A consumer-oriented website that brings together authoritative information from the U.S. National Library of Medicine, the National Institutes of Health, and other government agencies and health-related organizations. Includes extensive information about drugs, an illustrated medical encyclopedia, interactive patient tutorials, and recent health news.
PubMed
A service of the U.S. National Library of Medicine that includes over 17 million citations from academic journals for biomedical articles dating back to the 1950s. Includes links to many abstracts, full text articles, and other related resources.
National Guideline Clearninghouse
A resource sponsored by the Agency for Healthcare Research and Quality that gives information on current guidelines for the diagnosis and treatment of diseases.
Merck Manuals Online Medical Library
Includes the "Merck Manuals Home Edition," which explains disorders, who is likely to get them, their symptoms, how they're diagnosed, how they might be prevented, how they can be treated, and prognoses. Also includes the "Merck Manual of Health and Aging" and other resources.
University of Pittsburgh Medical Center-Managing Your Health
Consumer-oriented website with information on conditions and diseases, procedures, and drugs. Includes an "anatomy navigator," health tools and calculators, a medical dictionary, and other resources.
Our survey of physicians included the following open-ended
request of the doctors: "If there are any major kinds of cases in which you
would want your loved one to get care at a medical center in some other part of
the country, please tell us below the type(s) of cases and the name(s) and
location(s) of the facility or facilities you would recommend."
This was a very informal approach, and compiling a list of
medical centers for you from the named facilities was a judgmental process for
us. Since some types of diseases were mentioned only a few times, we listed
some centers with only a few mentions; for frequently mentioned diseases, the
threshold was higher.
For the most part, the following list addresses broad
categories of cases. You might want a facility that has expertise in your
particular condition, defined much more narrowly. Still, you might find it
useful to use one of the listed facilities as a starting point for getting more
specific referrals.
There are many types of cases that are not covered. That is
simply because we got too few mentions of those types to be useful.
We include this informal list because we think you might
find it a useful addition to the much more quantitative information presented
elsewhere in this book.
| Types of Cases | Hospital | City | State |
| Allergy/asthma | National Jewish Health Center | Denver | CO |
| Bone marrow transplant | Fred Hutchinson Cancer Research Center | Seattle | WA |
| Bone marrow transplant | Duke University Hospital | Durham | NC |
| Cancer, brain | Duke University Hospital | Durham | NC |
| Cancer, brain | University of California, San Francisco | San Francisco | CA |
| Cancer, eyes | Wills Eye Institute | Philadelphia | PA |
| Cancer, pancreas | The Johns Hopkins Hospital | Baltimore | MD |
| Cancer, testicular | Indiana University Hospital | Indianapolis | IN |
| Cancer, general | The University of Texas MD Anderson Cancer Center | Houston | TX |
| Cancer, general | Memorial Sloan-Kettering Cancer Center | New York | NY |
| Cancer, general | Dana-Farber Cancer Institute | Boston | MA |
| Cancer, general | Mayo Clinic Hospitals | Rochester | MN |
| Cancer, general | City of Hope | Duarte | CA |
| Cancer, general | The Johns Hopkins Hospital | Baltimore | MD |
| Cancer, general | Duke University Hospital | Durham | NC |
| Cancer, general | Roswell Park Cancer Institute | Buffalo | NY |
| Colorectal surgery | Cleveland Clinic | Cleveland | OH |
| Crohn's disease/inflamatory bowel | Cleveland Clinic | Cleveland | OH |
| Crohn's disease/inflamatory bowel | Mayo Clinic Hospitals | Rochester | MN |
| Eyes | Bascom Eye Institute, University of Miami | Miami | FL |
| Eyes | Wills Eye Institute | Philadelphia | PA |
| Eyes | UCLA Medical Center | Los Angeles | CA |
| Eyes | Wilmer Eye Institute, The Johns Hopkins Hospital | Baltimore | MD |
| Gastrointestinal, general | Cleveland Clinic | Cleveland | OH |
| Gastrointestinal, general | Mayo Clinic Hospitals | Rochester | MN |
| Heart, general | Cleveland Clinic | Cleveland | OH |
| Heart, general | Mayo Clinic Hospitals | Rochester | MN |
| Heart, general | Children's Hospital Boston | Boston | MA |
| Heart, general | New York-Presbyterian/Columbia | New York | NY |
| Heart, general | Massachusetts General Hospital | Boston | MA |
| Heart, general | Brigham and Women's Hospital | Boston | MA |
| Heart, general | The Johns Hopkins Hospital | Baltimore | MD |
| Heart, general | Stanford University Medical Center | Palo Alto | CA |
| Heart, general | Texas Heart Institute at St. Luke's Episcopal Hospital | Houston | TX |
| Infectious disease | Mayo Clinic Hospitals | Rochester | MN |
| Kidney | Cleveland Clinic | Cleveland | OH |
| Lung | National Jewish Health Center | Denver | CO |
| Lung | University of California, San Diego | San Diego | CA |
| Mystery diagnoses | Mayo Clinic Hospitals | Rochester | MN |
| Mystery diagnoses | Cleveland Clinic | Cleveland | OH |
| Mystery diagnoses | The Johns Hopkins Hospital | Baltimore | MD |
| Mystery diagnoses | Massachusetts General Hospital | Boston | MA |
| Mystery diagnoses | UCLA Medical Center | Los Angeles | CA |
| Neurology | Mayo Clinic Hospitals | Rochester | MN |
| Neurology | Cleveland Clinic | Cleveland | OH |
| Neurosurgery | Duke University Hospital | Durham | NC |
| Neurosurgery | Mayo Clinic Hospitals | Rochester | MN |
| Neurosurgery | University of California, San Francisco | San Francisco | CA |
| Neurosurgery | | | |
| Neurosurgery | Cleveland Clinic | Cleveland | OH |
| Neurosurgery | Massachusetts General Hospital | Boston | MA |
| Neurosurgery | The Johns Hopkins Hospital | Baltimore | MD |
| Neurosurgery | UCLA Medical Center | Los Angeles | CA |
| Orthopedics | Hospital for Special Surgery | New York | NY |
| Orthopedics | Mayo Clinic Hospitals | Rochester | MN |
| Orthopedics | Cleveland Clinic | Cleveland | OH |
| Orthopedics | Massachusetts General Hospital | Boston | MA |
| Pediatrics, many types of cases | Children's Hospital Boston | Boston | MA |
| Pediatrics, many types of cases | Children's Hospital of Philadelphia | Philadelphia | PA |
| Pediatrics, many types of cases | Cincinnati Children's Hospital Medical Center | Cincinnati | OH |
| Pediatrics, many types of cases | The Johns Hopkins Hospital | Baltimore | MD |
| Prostate | The Johns Hopkins Hospital | Baltimore | MD |
| Rheumatology | Mayo Clinic Hospitals | Rochester | MN |
| Spine surgery | The Johns Hopkins Hospital | Baltimore | MD |
| Surgery, general | Mayo Clinic Hospitals | Rochester | MN |
| Surgery, general | Cleveland Clinic | Cleveland | OH |
| Surgery, general | Children's Hospital Boston | Boston | MA |
| Surgery, general | The Johns Hopkins Hospital | Baltimore | MD |
| Surgery, general | Massachusetts General Hospital | Boston | MA |
| Transplant, heart | Cleveland Clinic | Cleveland | OH |
| Transplant, heart | Stanford University Medical Center | Palo Alto | CA |
| Transplant, heart | UCLA Medical Center | Los Angeles | CA |
| Transplant, lung | Stanford University Medical Center | Palo Alto | CA |
| Transplant, liver | University of Pittsburgh Medical Center Presbyterian and Eye & Ear Institute | Pittsburgh | PA |
| Transplant, liver | UCLA Medical Center | Los Angeles | CA |
| Transplant, liver | Cleveland Clinic | Cleveland | OH |
| Transplant, liver | University of California, San Francisco | San Francisco | CA |
| Transplant, liver | Duke University Hospital | Durham | NC |
| Transplant, general | University of Pittsburgh Medical Center Presbyterian and Eye & Ear Institute | Pittsburgh | PA |
| Transplant, general | UCLA Medical Center | Los Angeles | CA |
| Transplant, general | Cleveland Clinic | Cleveland | OH |
| Urology | Cleveland Clinic | Cleveland | OH |
| Urology | The Johns Hopkins Hospital | Baltimore | MD |
| Vascular disease | Cleveland Clinic | Cleveland | OH |
| Vascular disease | Brigham and Women's Hospital | Boston | MA |
| Vascular disease | Massachusetts General Hospital | Boston | MA |
| Vascular disease | Mayo Clinic Hospitals | Rochester | MN |
| Many types of cases | Mayo Clinic Hospitals | Rochester | MN |
| Many types of cases | Cleveland Clinic | Cleveland | OH |
| Many types of cases | The Johns Hopkins Hospital | Baltimore | MD |
| Many types of cases | UCLA Medical Center | Los Angeles | CA |
| Many types of cases | Massachusetts General Hospital | Boston | MA |
| Many types of cases | The University of Texas MD Anderson Cancer Center | Houston | TX |
| Many types of cases | Duke University Hospital | Durham | NC |
The types of cases used in our calculation of risk-adjusted
death rates did not include cases in which cancer was the diagnosis listed as
the primary reason for hospital admission. Calculating risk-adjusted death
rates is not as meaningful for cancer cases as for many other types of cases.
Often, what the hospital does can have little or no effect on whether the
patient dies within 30 days after hospital admission, which is the period for
which the hospital death rates were calculated. The death from cancer may be
unavoidable, and the hospital's efforts may be focused on pain reduction or
treatment of secondary problems. Some hospitals may have a higher proportion of
advanced cancer cases than other hospitals have, depending in part on community
customs and resources for treating such cases in nursing homes, hospices, or
other settings.
Nonetheless, it is important to choose a top-quality
institution for the treatment of cancer, whether inpatient or outpatient.
Choice of such an institution might have a big effect on the long-term outcome.
One indication of an institution's competence in the
treatment of cancer is designation by the National Cancer Institute
(NCI) as a Comprehensive Cancer Center or a Clinical Cancer Center.
This designation is given to major academic and research institutions
throughout the United States with broad-based, coordinated, interdisciplinary
programs in cancer research. These institutions have been selected by the
NCI for scientific excellence and capability to integrate a
diversity of research approaches to focus on the problem of cancer. In addition
to doing research, the institutions also treat patients.
A further indication of an institution's competence in
treating cancer is membership in the National Comprehensive Cancer
Network (NCCN). NCCN is a not-for-profit alliance of
leading cancer centers. It seeks to help member institutions to do excellent
research, measure the outcomes of the care they provide, and provide
state-of-the-art cancer care to as many patients as possible.
At www.nccn.org/members you will find a list
of NCI-designated Comprehensive and Clinical Cancer Centers and NCCN network
members. Bear in mind that there are many other high-quality institutions that
might be more convenient for you, but you or your physician might want to seek
advice or referrals from professionals at the listed institutions.
Another indicator of hospital quality, not shown on our Ratings
Tables, is recognition of a hospital by the Magnet Recognition Program, which
was developed by the American Nurses Credentialing Center to identify
healthcare organizations that provide the best in nursing care. Over 300 acute-care
hospitals currently have this recognition. They are listed below. We have found
that these hospitals also have significantly lower risk-adjusted mortality
rates than other hospitals in our "all cases" category, and they were rated
much higher than other hospitals by the physicians we surveyed.
For more information on this program, visit www.nursecredentialing.org.
- Alaska Native Medical Center, Anchorage, AK
- Children's Hospital of Alabama, Birmingham, AL
- UAB Hospital, Birmingham, AL
- Banner Good Samaritan Medical Center, Phoenix, AZ
- John C. Lincoln North Mountain Hospital, Phoenix, AZ
- Scottsdale Healthcare Osborn, Scottsdale, AZ
- Scottsdale Healthcare Shea, Scottsdale, AZ
- University Medical Center, Tucson, AZ
- Cedars-Sinai Medical Center, Los Angeles, CA
- Children's Hospital Central California, Madera, CA
- Children's Hospital of Orange County, Orange, CA
- Childrens Hospital Los Angeles, Los Angeles, CA
- El Camino Hospital, Mountain View, CA
- Hoag Memorial Hospital Presbyterian, Newport Beach, CA
- John Muir Medical Center--Walnut Creek Campus, Walnut Creek, CA
- Providence Holy Cross Medical Center, Mission Hills, CA
- Ronald Reagan UCLA Medical Center, Los Angeles, CA
- St. Joseph Hospital, Orange, CA
- Scripps Memorial Hospital La Jolla, La Jolla, CA
- Sharp Grossmont Hospital, La Mesa, CA
- Sharp Memorial Hospital, San Diego, CA
- Stanford University Medical Center, Palo Alto, CA
- University of California Irvine Medical Center, Orange, CA
- The Children's Hospital, Aurora, CO
- The Medical Center of Aurora, Aurora, CO
- North Colorado Medical Center, Greeley, CO
- Porter Adventist Hospital, Denver, CO
- Poudre Valley Hospital, Fort Collins, CO
- University of Colorado Hospital, Aurora, CO
- Middlesex Hospital, Middletown, CT
- Stamford Hospital, Stamford, CT
- Georgetown University Hospital, Washington, DC
- Baptist Hospital of Miami, Miami, FL
- Baptist Medical Center Beaches, Jacksonville, FL
- Baptist Medical Center Downtown, Jacksonville, FL
- Baptist Medical Center Nassau, Fernandina Beach, FL
- Baptist Medical Center South, Jacksonville, FL
- Flagler Hospital, St Augustine, FL
- Holy Cross Hospital, Fort Lauderdale, FL
- Mease Countryside Hospital, Safety Harbor, FL
- Mease Dunedin Hospital, Dunedin, FL
- Memorial Hospital West, Pembroke Pines, FL
- Mercy Hospital, Miami, FL
- Miami Children's Hospital, Miami, FL
- Morton Plant Hospital, Clearwater, FL
- Morton Plant North Bay Hospital, New Port Richey, FL
- Sarasota Memorial Hospital, Sarasota, FL
- Shands Children's Hospitals at UF, Gainesville, FL
- South Miami Hospital, South Miami, FL
- Tampa General Hospital, Tampa, FL
- Winter Haven Hospital, Winter Haven, FL
- The Medical Center of Central Georgia, Macon, GA
- Candler Hospital, Savannah, GA
- St. Joseph's Hospital, Savannah, GA
- Saint Joseph's Hospital of Atlanta, Atlanta, GA
- University Hospital, Augusta, GA
- Alegent Health Mercy Hospital--Council Bluffs, Council Bluffs, IA
- Genesis Medical Center, Davemport--East Rusholme Street, Davenport, IA
- Genesis Medical Center, Davenport--West Central Park, Davenport, IA
- Mercy Medical Center--Dubuque, Dubuque, IA
- Trinity Medical Center--Terrace Park Campus, Bettendorf, IA
- University of Iowa Hospitals & Clinics, Iowa City, IA
- Kootenai Medical Center, Coeur d'Alene, ID
- St. Luke's Boise Medical Center, Boise, ID
- Advocate Christ Medical Center, Oak Lawn, IL
- Advocate Illinois Masonic Medical Center, Chicago, IL
- Advocate Lutheran General Hospital, Park Ridge, IL
- Children's Memorial Hospital, Chicago, IL
- Delnor-Community Hospital, Geneva, IL
- Edward Hospital, Naperville, IL
- Memorial Hospital, Belleville, IL
- Memorial Medical Center, Springfield, IL
- Methodist Medical Center of Illinois, Peoria, IL
- Northwest Community Hospital, Arlington Heights, IL
- Northwestern Memorial Hospital, Chicago, IL
- OSF St. Anthony Medical Center, Rockford, IL
- OSF St. Francis Medical Center, Peoria, IL
- OSF St. Joseph Medical Center, Bloomington, IL
- Rush University Medical Center, Chicago, IL
- Trinity Medical Center--7th Street Campus, Moline, IL
- Trinity Medical Center--West Campus, Rock Island, IL
- University of Chicago Medical Center, Chicago, IL
- Columbus Regional Hospital, Columbus, IN
- Good Samaritan Hospital, Vincennes, IN
- Goshen General Hospital, Goshen, IN
- Indiana University Hospital, Indianapolis, IN
- La Porte Hospital, La Porte, IN
- Lutheran Hospital of Indiana, Fort Wayne, IN
- Marion General Hospital, Marion, IN
- Methodist Hospital, Indianapolis, IN
- Riley Hospital for Children, Indianapolis, IN
- Schneck Medical Center, Seymour, IN
- The University of Kansas Hospital, Kansas City, KS
- Stormont-Vail Regional Health Center, Topeka, KS
- Baptist Hospital East, Louisville, KY
- Central Baptist Hospital, Lexington, KY
- Kosair Children's Hospital, Louisville, KY
- St. Elizabeth Medical Center South Unit (Edgewood), Edgewood, KY
- UK Albert B. Chandler Hospital, Lexington, KY
- East Jefferson General Hospital, Metairie, LA
- Ochsner Medical Center--New Orleans, New Orleans, LA
- Woman's Hospital, Baton Rouge, LA
- Baystate Medical Center, Springfield, MA
- Children's Hospital Boston, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Massachusetts General Hospital, Boston, MA
- Winchester Hospital, Winchester, MA
- The Johns Hopkins Hospital, Baltimore, MD
- Franklin Square Hospital Center, Baltimore, MD
- Sinai Hospital of Baltimore, Baltimore, MD
- Maine Medical Center, Portland, ME
- Beaumont Hospital Royal Oak, Royal Oak, MI
- Children's Hospital of Michigan, Detroit, MI
- Holland Hospital, Holland, MI
- Munson Medical Center, Traverse City, MI
- Abbott Northwestern Hospital, Minneapolis, MN
- Children's Hospital, Minneapolis, MN
- Children's Hospital, St Paul, MN
- Fairview Ridges Hospital, Burnsville, MN
- Rochester Methodist Hospital, Rochester, MN
- St. Cloud Hospital, St Cloud, MN
- St. Marys Hospital, Rochester, MN
- University of Minnesota Medical Center, Fairview--Riverside Campus, Minneapolis, MN
- University of Minnesota Medical Center, Fairview--University Campus, Minneapolis, MN
- Barnes-Jewish Hospital, St Louis, MO
- Boone Hospital Center, Columbia, MO
- Children's Mercy Hospital, Kansas City, MO
- St. Joseph Medical Center, Kansas City, MO
- St. Louis Children's Hospital, St Louis, MO
- Saint Luke's Hospital, Kansas City, MO
- St. Mary's Medical Center, Blue Springs, MO
- Southeast Missouri Hospital, Cape Girardeau, MO
- Billings Clinic, Billings, MT
- Annie Penn Hospital, Reidsville, NC
- Catawba Valley Medical Center, Hickory, NC
- Duke Raleigh Hospital, Raleigh, NC
- Duke University Hospital, Durham, NC
- Durham Regional Hospital, Durham, NC
- FirstHealth Moore Regional Hospital, Pinehurst, NC
- Forsyth Medical Center, Winston-Salem, NC
- Gaston Memorial Hospital, Gastonia, NC
- High Point Regional Health System, High Point, NC
- Lake Norman Regional Medical Center, Mooresville, NC
- Moses H. Cone Memorial Hospital, Greensboro, NC
- Presbyterian Hospital, Charlotte, NC
- Presbyterian Hospital Huntersville, Huntersville, NC
- Presbyterian Hospital Matthews, Matthews, NC
- Presbyterian Orthopaedic Hospital, Charlotte, NC
- Rex Hospital, Raleigh, NC
- Southeastern Regional Medical Center, Lumberton, NC
- Wake Forest University Baptist Medical Center, Winston-Salem, NC
- Wesley Long Community Hospital, Greensboro, NC
- Women's Hospital of Greensboro, Greensboro, NC
- Medcenter One Hospital, Bismarck, ND
- St. Alexius Medical Center, Bismarck, ND
- The Nebraska Medical Center, Omaha, NE
- Alegent Health Lakeside Hospital, Omaha, NE
- Methodist Hospital, Omaha, NE
- Saint Elizabeth Regional Medical Center, Lincoln, NE
- Mary Hitchcock Memorial Hospital, Lebanon, NH
- St. Joseph Hospital, Nashua, NH
- Southern New Hampshire Medical Center, Nashua, NH
- The Jersey City Medical Center, Jersey City, NJ
- The Valley Hospital, Ridgewood, NJ
- AtlantiCare Regional Medical Center--City Campus, Atlantic City, NJ
- AtlantiCare Regional Medical Center--Mainland Campus, Pomona, NJ
- Capital Health System--Fuld Campus, Trenton, NJ
- Capital Health System--Mercer Campus, Trenton, NJ
- CentraState Medical Center, Freehold, NJ
- Englewood Hospital & Medical Center, Englewood, NJ
- Hackensack University Medical Center, Hackensack, NJ
- Hunterdon Medical Center, Flemington, NJ
- Jersey Shore University Medical Center, Neptune, NJ
- Kimball Medical Center, Lakewood, NJ
- Morristown Memorial Hospital, Morristown, NJ
- Ocean Medical Center, Brick, NJ
- Raritan Bay Medical Center Perth Amboy, Perth Amboy, NJ
- Riverview Medical Center, Red Bank, NJ
- Robert Wood Johnson University Hospital, New Brunswick, NJ
- St. Francis Medical Center, Trenton, NJ
- St. Joseph's Regional Medical Center, Paterson, NJ
- Saint Peter's University Hospital, New Brunswick, NJ
- South Jersey Healthcare Elmer Hospital, Elmer, NJ
- South Jersey Healthcare Regional Medical Center, Vineland,
NJ
- The Mount Sinai Hospital, New York, NY
- Elmhurst Hospital Center, Elmhurst, NY
- F. F. Thompson Hospital, Canandaigua, NY
- Good Samaritan Hospital Medical Center, West Islip, NY
- Hospital for Special Surgery, New York, NY
- Hudson Valley Hospital Center, Cortlandt Manor, NY
- Huntington Hospital, Huntington, NY
- Lourdes Hospital, Binghamton, NY
- Mary Imogene Bassett Hospital, Cooperstown, NY
- NYU Langone Medical Center, New York, NY
- Rochester General Hospital, Rochester, NY
- St. Francis Hospital, Roslyn, NY
- St. Joseph's Hospital Health Center, Syracuse, NY
- St. Peter's Hospital, Albany, NY
- Saratoga Hospital, Saratoga Springs, NY
- Strong Memorial Hospital, Rochester, NY
- Akron Children's Hospital, Akron, OH
- Aultman Hospital, Canton, OH
- Cincinnati Children's Hospital Medical Center, Cincinnati,
OH
- Cleveland Clinic, Cleveland, OH
- EMH Regional Medical Center, Elyria, OH
- Fairview Hospital, Cleveland, OH
- Good Samaritan Hospital, Dayton, OH
- Grant Medical Center, Columbus, OH
- Kettering Medical Center, Kettering, OH
- Kettering Medical Center--Sycamore, Miamisburg, OH
- MetroHealth Medical Center, Cleveland, OH
- Miami Valley Hospital, Dayton, OH
- Nationwide Children's Hospital, Columbus, OH
- Ohio State University Hospital, Columbus, OH
- Riverside Methodist Hospital, Columbus, OH
- Robinson Memorial Hospital, Ravenna, OH
- St. Elizabeth Health Center, Youngstown, OH
- St. Joseph Health Center, Warren, OH
- Shriners Hospital for Children Cincinnati, Cincinnati, OH
- Southern Ohio Medical Center, Portsmouth, OH
- University Hospitals Case Medical Center, Cleveland, OH
- Upper Valley Medical Center, Troy, OH
- INTEGRIS Baptist Medical Center, Oklahoma City, OK
- Mercy Health Center, Oklahoma City, OK
- Providence Portland Medical Center, Portland, OR
- Providence St. Vincent Medical Center, Portland, OR
- The Children's Hospital of Philadelphia, Philadelphia, PA
- Abington Memorial Hospital, Abington, PA
- Bryn Mawr Hospital, Bryn Mawr, PA
- Fox Chase Cancer Center, Philadelphia, PA
- Geisinger Medical Center, Danville, PA
- Hospital of the University of Pennsylvania, Philadelphia, PA
- Lancaster General Hospital, Lancaster, PA
- Lankenau Hospital, Wynnewood, PA
- Lehigh Valley Hospital, Allentown, PA
- Paoli Hospital, Paoli, PA
- Penn State Milton S. Hershey Medical Center, Hershey, PA
- Pinnacle Health--Community Campus, Harrisburg, PA
- Pinnacle Health--Harrisburg Campus, Harrisburg, PA
- Robert Packer Hospital, Sayle, PA
- St. Christopher's Hospital for Children, Philadelphia, PA
- Thomas Jefferson University Hospital, Philadelphia, PA
- UPMC St. Margaret, Pittsburgh, PA
- Western Pennsylvania Hospital, Pittsburgh, PA
- York Hospital, York, PA
- The Miriam Hospital, Providence, RI
- Newport Hospital, Newport, RI
- Spartanburg Regional, Spartanburg, SC
- Avera McKennan Hospital & University Health Center, Sioux
Falls, SD
- Sanford USD Medical Center, Sioux Falls, SD
- Johnson City Medical Center, Johnson City, TN
- Monroe Carell, Jr. Children's Hospital at Vanderbilt,
Nashville, TN
- Vanderbilt Medical Center, Nashville, TN
- The Methodist Hospital, Houston, TX
- The University of Texas M. D. Anderson Cancer Center,
Houston, TX
- Baylor Jack and Jane Hamilton Heart & Vascular Hospital,
Dallas, TX
- Baylor University Medical Center at Dallas, Dallas, TX
- Children's Medical Center Dallas, Dallas, TX
- CHRISTUS Hospital--St. Elizabeth, Beaumont, TX
- CHRISTUS Hospital--St. Mary, Port Arthur, TX
- Cook Children's Medical Center, Fort Worth, TX
- Dell Children's Medical Center of Central Texas, Austin, TX
- Harris Methodist Fort Worth Hospital, Fort Worth, TX
- Medical Center of Plano, Plano, TX
- Medical City Hospital/Medical City Children's Hospital,
Dallas, TX
- Memorial Hermann Baptist Hospital--Beaumont Campus,
Beaumont, TX
- Presbyterian Hospital of Dallas, Dallas, TX
- Presbyterian Hospital of Plano, Plano, TX
- St. Luke's Episcopal Hospital, Houston, TX
- Seton Medical Center Austin, Austin, TX
- Seton Northwest Hospital, Austin, TX
- Texas Children's Hospital, Houston, TX
- University Medical Center at Brackenridge, Austin, TX
- University of Texas Medial Branch at Galveston, Galveston,
TX
- The Orthopaedic Specialty Hospital, Murray, UT
- Alta View Hospital, Sandy, UT
- American Fork Hosptial, American Fork, UT
- Intermountain Medical Center, Murray, UT
- LDS Hospital, Salt Lake City, UT
- Orem Community Hospital, Orem, UT
- Utah Valley Regional Medical Center, Provo, UT
- Carilion Roanoke Memorial Hospital, Roanoke, VA
- Inova Fair Oaks Hospital, Fairfax, VA
- Inova Fairfax Hospital, Falls Church, VA
- Inova Loudoun Hospital, Leesburg, VA
- Lynchburg General Hospital, Lynchburg, VA
- Martha Jefferson Hospital, Charlottesville, VA
- Memorial Regional Medical Center, Mechanicsville, VA
- Montgomery Regional Hospital, Blacksburg, VA
- Reston Hospital Center, Reston, VA
- St. Mary's Hospital, Richmond, VA
- Sentara Norfolk General Hospital, Norfolk, VA
- University Health System, Charlottesville, VA
- Virginia Baptist Hospital, Lynchburg, VA
- Virginia Commonwealth University Medical Center, Richmond,
VA
- Winchester Medical Center, Winchester, VA
- Southwestern Vermont Medical Center, Bennington, VT
- Children's Hospital & Regional Medical Center, Seattle,
WA
- University of Washington Medical Center, Seattle, WA
- Aspirus Wausau Hospital, Wausau, WI
- Aurora Medical Center, Hartford, WI
- Aurora St. Lukes Medical Center, Milwaukee, WI
- Aurora Sinai Medical Center, Milwaukee, WI
- Children's Hospital of Wisconsin, Wauwatosa, WI
- Froedtert Memorial Lutheran Hospital, Milwaukee, WI
- St. Joseph Hospital, Milwaukee, WI
- St. Joseph's Hospital, Marshfield, WI
- St. Mary's Hospital, Madison, WI
- City Hospital, Martinsburg, WV
- Jefferson Memorial Hospital, Ranson, WV
- Ruby Memorial Hospital, Morgantown, WV
- West Virginia University Children's Hospital, Morgantown, WV
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