Truly Intensive Care
There's nothing like considering one's own mortality to focus the mind. You can easily do that as you lie on a gurney in an emergency room. Or as you're rolled into an intensive care unit clutching your chest, or perhaps glide down a busy corridor toward a cardiac catheterization lab or operating room. These are everyday places in the lives of hospitals, but in your life they are infrequent and mostly unexpected journeys into a world where every turn lets you know that you are in someone else's hands. You give thanks for the kind and efficient souls around you and hope that your trust in their expertise is well placed.
Hospitals all over America have become high-impact places that heavily influence the mortality associated with major illnesses and their treatment. These outwardly inanimate, quiet-zoned hospitals teem with trained professionals in command of powerful arsenals of diagnostic technology, drugs, devices, and surgical interventions brought to bear on increasingly fragile patients in the course of brief encounters. Among other feats, they are mending hearts, exterminating cancers, reversing early strokes, and replacing shattered bones. And all the nooks and crannies of the hospital weigh in with the latest knowledge and technology. For most of America's hospitals, many of the sick assigned to regular hospital beds would have been in intensive care units a decade ago, and many patients in today's ICU s would not have been alive. The hospital has become a powerful living organism that renders intensive care. Although you may be admitted under the name of one doctor, you become the hospital's patient as well.
In the know. What drove that message home were public disclosures beginning in 1992 by New York, and later Pennsylvania, California, and a few other states, of widely varying mortality rates at different hospitals when coronary artery surgery was performed on patients with similar risks. It was a burning embarrassment and a clear refutation of the pretense that doctors and hospitals are all the same. Despite arguments that the differences were due to varying patient infirmities rather than medical performance, down deep most doctors felt there was something to this. Doctors have always known the doctors to go to--and the places to avoid.
But something wonderful happened, in part related to the unfortunate medical humiliation: Almost overnight, hospital mortality at the poorer sites improved. Weak doctors quietly made their exodus; others took on less sick patients, perhaps sending the higher-risk cases elsewhere. Shining a little bit of light on performance ultimately helped legions of patients.
Before the numbers were publicized, the mortality rate for coronary bypass surgery in New York medical centers ranged from under 2 to 8 percent. Similarly large spreads typically occurred with cardiac valve replacement, congenital heart surgery, and the management of heart attacks. Considering the millions of people having cardiac procedures each year, better quality quickly added up to 100,000 lives saved in this area alone. Furthermore, studies have shown that hospitals with high performance in one heart procedure also do better in others, and the lower performers are also lower across the board. This reinforces the importance of systems and processes as well as physician talent.
That's what quality gurus are banking on, such as the Leapfrog Group, a consortium of private and public healthcare purchasers, which wants hospitals to audit and publicly disclose patient results. And the Institute for Healthcare Improvement is rallying medical centers to create rapid-response teams to bring intensive care to bedsides in all parts of the hospital. Better outcomes invariably mean a hospital culture with a top-notch medical staff that works together, strong and respected nursing, well-equipped and well-functioning intensive care units, and ever-upgraded medical technology. Experience counts, too, with hospitals and physicians who perform the larger numbers of difficult procedures consistently demonstrating lower mortality rates and better overall results.
For years, U.S. News has keyed on several measures to devise the "America's Best Hospitals" rankings: mortality, reputation among specialist physicians, nursing, technology, and more. Increasingly, we identify critical specialty areas. However, consumers want more. A reader, Tom Mulhall, from Ponte Vedra Beach, Fla., wrote to me last week praising "the excellent service" that we offer with our "Best Hospitals" listings but made a plea for even more refinement. Who's best, he asks, to treat sarcoidosis or to fix a Dupuytren's contracture of the hand? Just now, Mr. Mulhall, we don't have access to the kind of data to let us do that--but under the relentless glare of quality measures and pressure from information-hungry patients, we will get there.
This story appears in the July 18, 2005 print edition of U.S. News & World Report.