Finding the Right Hospital

What's good for patient satisfaction may not be good for medicine. Awash in marketing, the key questions to consider when choosing a hospital
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Hospital marketing has reached a frenzy. It is nearly impossible to drive around metropolitan areas in the U.S. without being barraged by billboards trumpeting hospitals' cutting-edge technology, luxurious facilities, or the lives of patients they have saved. In many markets, more than one hospital claims a "Top 100," "Top 10," or even "#1" rating for the same type of service. Especially while recalling a day when such advertising would have seemed sordid, it's easy to feel bewildered.

Some of the most important events of our lives, including birth and death, often take place within their walls. We entrust our lives to the nurses, physicians, and other health professionals who populate them. And the services they provide cost a great deal of money -- last year one-third of all healthcare expenditures, or nearly $900 billion. For those who have a choice, how should we determine which hospital is right for us?

Suppose one hospital's program has a 99 percent success rate, while another has only a 95 percent success rate. It would be tempting to suppose the first is better.

One option is to choose according to amenities. How much original artwork adorns its corridors? How high is the thread count in its sheets? Does it offer the services of a concierge or gourmet chef? Of course it is quite possible to be comfortably ensconced in the lap of luxury yet mishandled medically.

We might go from lot to lot to find the best deal on a car, but few of us are able or willing to invest the time and effort that would be required to shop around for the best hospital. And even if we did, which healthcare parameters would we track? Merely finding out how many patients with a particular condition lived or died does not necessarily tell us much, in part because some hospitals' patients are sicker than others.

Take the case of heart surgery. Suppose one hospital's program has a 99 percent success rate, while another has only a 95 percent success rate. It would be tempting to suppose the first is better. But in fact, it might actually provide poorer care. For example, the 95 percent hospital might perform the procedure on the sickest patients in most dire need of the surgery, while the 99 percent hospital may only perform the procedure on relatively young and healthy patients, many of whom do not need it so much.

Another source of guidance is hospital choice might seem to be the satisfaction levels of former patients. Good hospital care should naturally produce satisfied patients, while bad care should produce unsatisfied ones. If only we could collect, quantify, and then make widely available the hospital experiences of former patients, we could determine where we are likely to get the best care for ourselves and our families.

In fact, both the Centers for Medicare and Medicaid Services and the National Committee on Quality Assurance require participating organizations to publicly report their patient satisfaction data. With such data in hand, the thinking goes, patients will be able to make more informed choices about where to seek care, and this in turn will spur competition between hospitals to improve patient experiences.

Yet the situation is not quite so simple. For one thing, it can be difficult for patients, most of whom have no background in healthcare, to distinguish between hospital staffs that are merely adequate and those that truly excel. In the case of surgical technique, for example, patients are generally unconscious, and when it comes to serious illnesses such as cancer and stroke, most of us happily have little or no prior experience with which to compare.

To be sure, we can generally discern whether the food is delicious or insipid, and whether someone is treating us in a polite or surly fashion. But we may not be able to tell whether or not the hospital staff arrived at the correct diagnosis, prescribed the appropriate therapy, or delivered the medications and procedures in a competent fashion. Especially when you are feeling poorly, it can be difficult to appraise quality of care.

High patient satisfaction may actually be associated with poorer care.

Despite having received first-rate medical care, some of us might rate a hospital experience poorly because we had to wait a long time, or personnel were brusque, or the food was not to our liking. On the other hand, we may rate another hospital experience highly because parking was both easy to find and free. Such parameters are not unimportant, but when it comes to choosing the best hospital for open-heart surgery, they may not be paramount.

There is some evidence that patient satisfaction is worse than a merely poor indicator of the quality of hospital care. High patient satisfaction may actually be associated with poorer care. A study last year in the Archives of Internal Medicine showed that patients with the highest satisfaction scores were more likely to be admitted to the hospital, spent more money on healthcare, and were 26 percent more likely to die than those with the lowest satisfaction.

What could account for this counterintuitive result? The answer is complex, but here is one important factor: some of us mistake more care for better care. For example, when we go to our physician complaining of a sore throat, we feel cheated if we do not emerge with a prescription for an antibiotic, even though the infection is viral and such medications offer no benefit. In fact, by altering the normal bacterial population of our gut and promoting the development of antibiotic-resistant bacteria in the community, such treatment may actually increase the illness burden. But we demand it anyway.

So merely giving us what we want, though great for patient satisfaction scores, may not be good medicine. What then can we rely on in choosing a hospital? One thing to bear in mind, where possible, is that most of should do what we can to avoid needing to go to the hospital in the first place. By eating well, exercising, and generally taking good care of ourselves, we can decrease the chance that we will need to be hospitalized.

After all, the healthiest people are not the ones who get the best hospital care. The healthiest people are the ones who do not need a hospital's services. With the possible exception of childbirth, the need to be cared for in a hospital is a sign that something has gone awry. Besides, hospitalization can actually be hazardous to your health. For example, at least 1 in 20 patients cared for in a hospital acquires a serious infection that requires additional treatment.

The differences between hospitals are also often not so great as billboards and television ads might lead us to suppose. For one thing, all hospitals undergo regular inspections and scrutiny by the same accrediting and certifying organizations, and typically the health professionals who practice in them have been educated at the same schools. In most cases, patients can get more or less equally good care at a number of competing institutions.

That being said, however, the best time to identify a preferred hospital is generally before the acute need arises. Here are the two key questions to consider: Do the people who work there, particularly nurses and physicians, seem generally happy and proud of the work they do? And, if health professionals were going to be hospitalized, which institution would they choose, and why? 

Ultimately, while hospitals work hard to establish their brands and convince patients that they offer superior service, we are cared for not by hospitals but by the people within. The hospital is but a tool, like a stethoscope or a CT scanner, in the hands of the health professionals who are the real source of excellence in care.

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Richard Gunderman, MD, PhD, is a correspondent for The Atlantic. He is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. Gunderman's most recent book is X-Ray Vision.

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