The renowned Mayo Clinic in Rochester, Minn., isn't that far from Mauston, Wis., where Don Wilke lives--only about a 2 1/2 hour drive. But when the 51-year-old bricklayer needed hip replacement surgery last March, he didn't need to make that trip. He went instead to a small hospital in Viroqua, Wis., a little over 50 miles away. Wilke was walking within days after orthopedist Jeffrey Lawrence implanted a metal joint in his left hip, and after a month he was feeling spry enough to make his annual spring turkey-hunting trip. "It's night and day," he says. "Before, when I came home from work, I just sat down. Now I can go out to the woodshop, garden, mow the lawn, or do whatever."
As Wilke and millions of others have learned, community hospitals can be just as good for some patients, even for those who need serious attention, as any glittery big-name center. "There's a lot of community hospitals that deliver excellent care," says David Flum, an associate professor of surgery at the University of Washington School of Medicine in Seattle who studies surgical outcomes. But not all community hospitals offer good care for all conditions. How can you tell whether a local hospital is right for you or when you should pack your bags? By getting information relevant to your illness or procedure, say Flum and other experts, about the hospital's performance and the doctor's experience.
Another name for community hospitals is primary-care facilities--a first stop for medical and surgical help, with few or no ties to academia or research. They are the mainstays of American hospital care. Of more than 35 million patients admitted in 2004, about 85 percent were to a community facility. That is where most hip and knee replacements, appendix removals, and some colon and prostate surgeries are now done. And like those in other demanding careers, many fine physicians who work in community hospitals do so because they traded big-city bustle and academic stress for a lower-velocity life.
Many people prefer local care, and there are measurable medical benefits from having family and friends close at hand. Studies show that people who have just had open-heart surgery have less pain and are quicker to get out of bed when they feel supported by others. "They just emotionally feel better if they have someone they could rely on," says Kathleen King, a professor of nursing at the University of Rochester's School of Nursing and author of one such investigation. "It's the day-to-day stuff that really helps people recover."
Obtaining the kind of information that experts like Flum want you to have probably won't be a snap. California, Maryland, New York, Pennsylvania, and Texas are among the handful of states that do put performance data about individual hospitals for some procedures, such as heart bypass surgery, on state health department websites. Many of the links to such sites are available at health carechoices.org for free. A $15 hospital performance report can be purchased from HealthGrades.com, but evaluations for procedures and conditions are in the form of broad star ratings rather than numbers. And while some community hospitals do appear in the "America's Best Hospitals" rankings--a tribute to their quality--primary-care centers are not the main focus.
For the most part, then, you'll have to do your own data gathering. A good place to start is with a principle that has generated stacks of medical studies: Practice may not make perfect, but it helps--a lot. "If a patient had to pick a single factor on which to choose a hospital and pick a surgeon, they would do better to focus on volume and experience than anything else,"says John Birkmeyer, a professor of surgery at the University of Michigan Medical School who has produced a fair share of the stacks himself. Doing a high volume of procedures hones a surgeon's skills, makes the operating room team more efficient and less error prone, and encourages hospitals to think harder about postoperative care and rehabilitation strategies.
The caveat is that while everyone agrees more is better, there is little agreement about just how many are enough. For a few procedures, studies have found evidence that argues for annual minimums (table, Page 78), and Medicare and some commercial health insurance plans require them in some cases. But many hospitals are at the low-volume end, and most procedures don't even have guidelines. For a particular one, you can ask several hospitals how many the busiest surgeon does annually, but the answers may still leave you wondering whether the number you were told is sufficient. You'll probably need to ask follow-up questions, probing for information on other quality measures.
Death and complication rates are the ultimate bottom line. But these numbers often are unavailable, and it isn't always obvious whether a good number means a good surgeon or just one who's had easier cases. The best approach is direct and personal, asking: What is your death rate at this hospital for this procedure? What is the complication rate? What are the rates for a patient like me? For prostate cancer, "I give patients names of my last 10 patients of similar age and stage of disease," says urologist James Eastham of Memorial Sloan-Kettering Cancer Center in New York. "If I just operated on 50-year-olds, my potency rates would look great," he says. "But if you're 72, that's not going to apply to you."
Posing such questions also offers an opportunity to test comfort level. Any physician should be willing to talk frankly about outcomes, various medical alternatives, and his or her own training and experience. If the reaction to such questions is vague or hostile, says Flum, "walk away."
Volume unequivocally matters in heart surgery, so U.S. News found a hospital in Texas that shows how patients can exploit that to find good local care. For hip replacement, a small Wisconsin hospital exemplifies how other quality measures can guide patients to good surgeons. And two hospitals--one in Ohio and one in Pennsylvania--demonstrate the complex choices involved in treating prostate cancer.
For more information, continue to Part 2 of our story.