Monday, July 23, 2007

America's Best Hospitals

The most recent issue (23rd July 2007) of US News and World Report, ranked the best hospitals in the USA. First on the honor roll is Johns Hopkins Hospital (Baltimore, MD), although the Mayo Clinic (Rochester, MN) scored a close second.The Cleveland Clinic (Cleveland, OH) led heart-hospital rankings nationally and in the Midwest. Tops in the Northeast was Brigham and Women's Hospital (Boston MA); in the South, Duke University Medical Center (Durham, NC); and in the West, Texas Heart Institute at St Luke's Episcopal Hospital (Houston). There are no surprises here.

I did not write this post in praise of American Hospitals. I was concerned that to rank these hospitals, the surveyors had to look into the outcomes of patients admitted to the centers. While this may sound like a reasonable criteria, at a cursory glance, an indepth look will make one quickly realise that just looking at outcomes without adjusting for the complexity of the case maybe unfair and even, unkind.

Recently, the state of California released their 2003-2004 rate adjusted CABG death rates by hospital and by surgeons. Some of their "senior and good" cardiac surgeons came out worst, obviously because they were taking on high-risk cases. Once they are "blacklisted" by such survey data, they will have trouble with health insurance providers, who may similarly "blacklist" them.

The big problem here is then surgeons will practice defensively and hit back by not taking on high-risk cases. Why should they? It then descends to a question of "my career or your survival", and this will be very bad for patient care no matter which side of the coin lands facing upwards. Who will risk taking on the bad ones?

Nearer to home, I understand that the Ministry of Health is looking on asking specialist to keep a logbook of their cases, noting the outcomes, especially for those who do surgery or invasive procedures. Although it is true that those who are poorly trained will have bad outcomes, those who take on high risk cases will also run the risk of poor outcomes. If MOH does not adjust the outcome data for the complexity of case (personally, I have not seen any easy way of adjusting for these variables internationally), then a good intention policy may risk being unfair and counter-productive. We all know which road is paved with good intentions and it is very important that the MOH takes a good look at where this may lead.

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