
Go to the Wrong Hospital and You’re 3 Times More Likely to Die - hvo
http://www.nytimes.com/2016/12/14/business/hospitals-death-rates-quality-vary-widely.html?src=me
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dsfyu404ed
FWIW local demographics have a non-negligible effect on a hospital's
specialty. The nearest hospital to a retirement community will get more
practice at heart attacks and strokes and the one in the college town will be
good at dealing with alcohol poisoning.

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gosub
from the abstract:

Risk-adjusted outcomes were calculated after adjusting for population factors,
co-morbidities, and health system factors. Even after risk-adjustment, there
exists large geographical variation in outcomes

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dzdt
That means they adjust for things like that heart attacks in 80-year-olds are
more likely fatal than in 40-year-olds, so a hospital serving mostly the
former is expected to have a lower survival rate for heart attack patients.

They are trying to measure differences in effectiveness for similar patients.
GP gives a possible explanation for such a difference : the hospital probably
gets good at the kinds of things it does a lot.

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MarkMc
This is so frustrating for me personally - I recently had to choose between
several hospitals without knowing anything about the historical patient
outcomes for each hospital.

A hundred years ago a doctor named Ernest Codman suggested that hospitals
should be rated by an "End Result System" [1] where paient outcomes were
measured and compared, yet only now do we have the "first comprehensive study
comparing how well individual hospitals treated a variety of medical
conditions". And we still do not know exactly which hospital is best and which
is worst.

To me the best way to judge a hospital is blindingly obvious: For each patient
at admission, estimate the chance he/she will be alive after 3 years. For
example, a 65-year-old woman who is a smoker, is overweight and has stage 2
lung cancer might have a 25% chance of being alive in 3 years. Then compare
the predicted outcome with the actual outcome. For example, say both Hospital
A and Hospital B both admit 100 patients with 20% predicted chance of
surviving 3 years. If after 3 years there are 30 such patients from Hospital A
still alive but only 10 such patients from Hospital B, it would strongly
indicate that Hospital A is better. We could look then at Hospital A for ways
to improve Hospital B.

What's so disheartening is that this process doesn't involve any special
technology. It could have been implemented 100 years ago, albeit with less
rigorous statistical methods. We spend a billion dollars on evaluating a drug
which has a marginal, one-off benfit for a few hundred thousand people. But we
ignore a process which is cheap and offers long-lasting benefits to millions
of people. It seems that the medical establishment is too powerful in this
case.

[1]
[https://en.wikipedia.org/wiki/Ernest_Amory_Codman](https://en.wikipedia.org/wiki/Ernest_Amory_Codman)

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nradov
It's not that simple, and it only seems blindingly obvious to you because you
haven't actually worked in healthcare. The trouble with using survival or
outcome ratings is that they effectively punish providers who take on the
hardest, riskiest cases. We simply don't have enough accurate data. And many
of the input variables aren't independent. The reality is that's it's
impossible to accurately quantify all the different factors which potentially
impact survival. So some providers find ways to game the system through
metrics arbitrage.

That said, it's still worthwhile to gather and use it for quality improvement.
We just have to be careful to treat it with appropriate caveats and look at
qualitative factors as well as quantified metrics.

~~~
monkmartinez
Spot on analysis. The complexity of the human factor, for want of a better
term, in healthcare is so hard to measure. I can only relate it to what I
know. That is, I work with several paramedics that are just "good" at
differential diagnosis. They would probably be excellent doctors, but life
didn't deal those cards in. I also work with "meh" paramedics that, if given
the choice, I wouldn't want taking care of my family. They do an adequate job
to the bare minimum standard set, but they are not great by any stretch of the
imagination. Both paramedics charge the same and carry the same title. Both
could miss something critical, or not. The fact is they are both humans
practicing paramedicine.

Until we automate the variability out of healthcare, we are stuck with
inconsistent results. Consider that roughly 70 years ago, lobotomies were
considered a valid medical procedure for psychiatric problems including
anxiety and depression.

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fapjacks
Maybe you will be surprised to learn that lobotomies are considered valid
medical procedures _to this day_.

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nickff
Outcomes vary widely by doctor/surgeon as well, but the medical profession has
successfully resisted meaningful measurement of results for many years now.

~~~
et2o
Most surgeons do not do enough cases over their entire careers to be
meaningfully compared to their peers. There was a big paper about this
recently. The ratings are a sham meant to instill false confidence.

~~~
mrestko
Can you link the paper?

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et2o
I can't remember what journal it was published in and google isn't helping.

I found this for hospital-level comparisons (these should be much more
accurate due to far larger numbers):
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250275/#!po=2....](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250275/#!po=2.94118)

However: "Most commonly reported outcome measures have low reliability for
differentiating hospital performance."

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toodlebunions
> The study did not disclose which hospitals had which results. Under the
> terms of the agreement to receive the data, the researchers agreed to keep
> the identities of the hospitals confidential.

Well that's not too useful for the patient oh I mean "consumer"

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cmdrfred
Its only a free market in ways that are convenient for them.

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coldtea
That has been the case with all free markets, ever.

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cmdrfred
Also every socialist or communist system. We have yet to resolve the
corruption problem without culling the ruling class every couple of decades.

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mturmon
They link to a heart surgery compilation by the Society of Thoracic Surgeons
([http://www.sts.org/quality-research-patient-safety/sts-
publi...](http://www.sts.org/quality-research-patient-safety/sts-public-
reporting-online)) which is fun to explore.

In metro LA, the top-tier hospitals (Cedars-Sinai, UCLA) have noticeably
better outcomes than regular hospitals. The difference is like 98.7% of
patients not dying versus 97.9% in a valve replacement ("AVR"). Flip it around
and it's 1.3% versus 2.1% -- definitely noticeable.

OTOH, UCSF (presumably top-tier, SF residents correct me if I'm mistaken) has
2.3% chance of dying. Maybe it's not a top-tier facility for AVR?

And further, a small midwestern hospital in Hays, KS (pop. 21000) has a 3.6%
chance of death. That's _huge_ next to Cedars-Sinai at 1.3%!

~~~
et2o
These ratings are not great because they incentivize doctors not to take more
complex cases. They claim to be risk-adjusted, but in reality you cannot
adjust for all possible risk factors. Lots of things in medicine are very
unique. There's very little that's more complex than human disease.

As a referral center for other referral centers, additionally UCSF will be
getting some of the most complicated cases in the world.

~~~
nchammas
> These ratings are not great because they incentivize doctors not to take
> more complex cases.

This reminds me of a scene in the recent Dr. Strange movie where the main
character -- a neurosurgeon -- turns down a case because it had a high risk of
failure and he didn't want to tarnish his perfect record.

> They claim to be risk-adjusted, but in reality you cannot adjust for all
> possible risk factors. Lots of things in medicine are very unique. There's
> very little that's more complex than human disease.

Isn't it better to approach the problem by improving how we do these risk
assessments so that the risk-adjusted ratings are fair, as opposed to leaving
patients in the dark about where to get the best care?

~~~
et2o
It's hard to just "improve the risk adjustments." The statistics aren't there.

I agree patients shouldn't be left in the dark. The most important thing is
getting the best care. There isn't an easy solution.

However, I think the existing solution hurts patients (and I have seen these
risk assessments first-hand numerous times).

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randyrand
So 4 options:

1\. make the good hospitals worse

2\. make the bad hospitals better

3\. combination of 1 & 2

4\. ignore

Most people will want to choose 2 but inadvertently choose 3. When in reality
we should have chosen 4.

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automatwon
Would saying "Go to the RIGHT hospital and you're 3 Times more likely to
live?" be equivalent?

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trendia
Not really. Suppose 1 / 100 people die at a good hospital and 3 / 100 die at a
bad hospital.

If you go to a bad hospital, you're 3x more likely to die. But if you go to a
good hospital, you're 99 / 97 or roughly 2% more likely to live.

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mjevans
Thank you, that's almost crystal clear.

Suppose 1 in 100 patients (for X) die at the best hospital and 3 in 100 die at
the worst.

Keeping percents the numbers are much less scare mongering.

    
    
      Best:  1% die, 99% live
      Worst: 3% die, 97% live
    

Comparing the percents makes it sound much more significant "three times"
(sounds like 300%, in an emotional sense).

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wyclif
Never get sick in the Philippines.

~~~
pavel_lishin
Can you expand on that?

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sjf
If it's anything like getting sick in India expect misdiagnosis, over-
prescription of drugs and prescription of drugs that are banned in the US.

~~~
ksjdj
samesies for cambodia

n=1 tho

~~~
BrandonM
I got 6 stitches in Cambodia for a major cut on my arm. No wait, seen by 3
medical professionals (including a doctor), in and out in 15 minutes. Total
cost: $15.

For me, that was a far better outcome than I would have received in the US for
a similar condition. Of course, stitches are pretty well understood; I can't
advocate for any other medical procedures in Cambodia.

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calebm
_Opens page_ , _Looks for graphs_ , "Nope... no graphs...", _Closes it_

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shawn-butler
I am struck by how similar this is to knowing how to choose a good school for
your children.

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known
Go the Wrong "Doctor" and You're 3 Times More Likely to Die

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pseingatl
Do you think the Secret Service knows, for example, which hospital is best for
gunshot victims? For stroke? For heart attacks? Of course they do. And yet,
when Hillary collapsed at the 9/11 Memorial, they took her to no hospital, but
to her daughter's apartment instead. Seems odd. Very odd.

