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January 19th, 2017

Hospital health check: why not all are created equal

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A new study of US health care has revealed that where you live can determine if you live

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The research uncovered large variability in health outcomes between states and within states

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We need greater transparency and a stronger focus on performance improvement

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We've all been there. The realisation that a trip to hospital is pending - either for treatment for yourself or to visit a sick friend or relative. Whatever the circumstance, though, you want and expect first-class treatment. Nothing else matters.

So goes the theory - what about the reality? What actually happens when you arrive at a hospital? Such questions have underpinned our recent exhaustive study of hospital admissions in the US. The results were striking. In short, we found that where you live can determine if you live.

Mapping US healthcare

It's certainly true to say that, here in the US, healthcare is rarely far from the headlines. Its affordability (or otherwise); its accessibility (or lack of); and its sheer cost (we spend more on healthcare than other developed nations, but our outcomes are generally no better) - these are all issues that demand resolution. No wonder it has long provided a fertile battleground for our political parties to joust over on Capitol Hill. The latest skirmish, concerning the Republicans' plans to repeal the Affordable Care Act, is poised to dominate the debate for weeks and months to come.

But what has received less analysis is the actual quality of the healthcare that Americans receive. First, the good news. There's no doubt that the US is home to some of the finest hospitals in the world, with patients from around the globe coming here for state-of-the-art treatment. This is a testament not only to the skill of our doctors and medical practitioners but also to the power of the nation's pioneering medical research.

Unfortunately, our study  - which attracted much media coverage - uncovered large variability in quality and health outcomes. Conducted in collaboration with Ariadne Labs, Harvard T.H. Chan School of Public Health, Alerion Institute, Johns Hopkins School of Medicine, University of Michigan Medical School, and the University of Rochester Department of Public Health, it demonstrated that outcomes vary dramatically from hospital to hospital. Patients in low-performing hospitals (the bottom 10%) are 3 times more likely to die and 13 times more likely to experience complications than those in high-performing ones (the top 10%). Even a hospital that has excellent outcomes for treating heart attacks, for example, might have far worse outcomes in treating a condition like diabetes.

These findings, alarming as they may be, are not the result of a limited piece of work - anything but. This was the most comprehensive analysis of health outcomes variation in the US to date, covering 22 million hospital admissions across states that account for over half of the US population, and including information from the federal Medicare and Medicaid programmes and private insurance companies.

We looked at specific health outcomes, including many common illnesses such as cardiovascular disease and pneumonia. And even after extensive risk assessment - adjusting the results for how sick the patients were and to take into account factors like age and income and other social determinants of health - the research found that the large variations in performance persisted across geographies.

Let's take just two examples. Even after risk adjustment, the probability of dying in the hospital after an acute event, such as a heart attack or stroke, is over twice as high at low-performing hospitals as at those in the top 10%. And patients were nearly 20 times more likely to experience central line blood infections at low-performing hospitals than at high-performing ones.

Moreover, the variation persists even within states or among hospitals in the same metropolitan area. For example, if you have an Acute Myocardial Infarction in Los Angeles, which has 17 hospitals, an ambulance might take you to a hospital with a 6% death rate or one with a 22% death rate. And it's not just down to socioeconomic factors. Thanks to the study, we also know that there are regions with low-performing hospitals that serve high-income, largely white populations and many regions with high-performing hospitals that serve low-income, minority populations - upending what was previously conventional wisdom.

From triage to treatment

So, we have diagnosed the problem - a great variation in outcomes across the US, between states and within states. But what treatment is available? It's clear that we need greater transparency and a stronger focus on performance improvement.

This means measuring and improving the outcomes that matter most to patients, such as death rates and complication rates. Hospitals, therefore, need to measure and share their risk-adjusted outcomes - a move that would create a more efficient, competitive and innovative healthcare market. In other words, improving the quality of healthcare is not just about spending more money.

But the bottom line - and the message that needs to cut through to reach citizens and policymakers, local, state and federal - is that not every hospital is the same. Think about it. Would you prefer a loved one to have their heart attack treated at your local hospital - which could have a death rate of 22% - or one a little further away where the rate is 6%?

As Congress and the new administration gear up for the latest chapter in the seemingly never-ending saga of healthcare reform, the opportunity for an improvement in outcomes is clear. Let's hope they take it - public impact doesn't get much more important.

Want to read more? Download the full study and check out the data visualisation tool 



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