Johns Hopkins Hospital is consistently named one of the best in the country. I can’t disagree with that; after all, I just started working there as an internist in September. Coincidentally, in the midst of the raging debate around health care reform, the past few months have seen increasing discussion of a small but crucial question: why do some of the best hospitals spend more money than others? If other hospitals named to the best-of lists consistently spend less money than my employer, shouldn’t we be emulating them instead? And how should an individual patient go about deciding which hospitals are the best for them?
What does it mean for a hospital to be “good”? On the one hand, the basis for the definition can be explicit standards – whether a hospital does those things that doctors think constitute quality care (for instance, timely antibiotics for pneumonia, beta-blockers after a heart attack, or the like). Those are the criteria used by federal payers, like Medicare and Medicaid, in their steadily growing pilot programs to reward doctors and hospitals for performance. It’s still controversial whether such programs encourage these quality-care steps, and, in the final analysis, lead to better outcomes: less death and disease.
But many patients look for a doctor or hospital on the basis of reputation. (For that matter, most health care professionals do the same when referring their patients, friends, or family to specialists.) Reputation can get a bad rap, especially by the followers of evidence-based medicine. It is not based on explicit standards, but on the say-so of an advice-giver or source of information which the patient respects. In fact, recent work suggest that the best-hospital rankings do not necessarily correlate with quality of care for common conditions.
Yet another definition of “good” is value: quality for money. I doubt whether an individual patient uses value to decide on hospitals, but certaintly many health services researchers think that value is important. Studies by researchers at Dartmouth claim that among the best performing hospitals in the country (as judged by the quality standards I mentioned above), there is as much as a factor of two difference in cost. However, researchers at UCLA recently published a study in the journal Circulation showing that California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. How these studies can be reconciled is still being debated.
What can we take away from these differing definitions? In the doctor’s office, the patient’s choices are what resolve the conflict between the recommendations of evidence-based medicine and their own personal preferences. Similarly, what makes for a “good hospital” might be all of the above – professional standards of excellence, wise use of resources, and (eventually, when the data allows) improved outcomes – interpreted by the preferences of the people involved.
Zackary Berger is a faculty member of the Johns Hopkins University School of Medicine, where he is an internist and researcher in general internal medicine.
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