Thursday, September 18, 2014

Speak Your Piece: Hospital Death Rates

04/09/2013

The headline probably caught your attention: “Why Rural Hospitals May Pose a Greater Risk of Death.” The story was based on a study that found rural “critical access hospitals” had a slightly worse mortality rate than major medical centers. 

"Greater risk of death" -- PBS Newshour ran this headline on its posting of the story. The study found a risk gap of 1.8% between the nation's largest, "medical Meccas" and small, rural hospitals designed to provide a basic level of care.The researchers got the numbers right. But they gave the wrong reasons for the small difference in survival between rural, critical access hospitals and larger regional hospitals. 

Rural America has over 1,300 critical access hospitals. Such a hospital is mainly a medical hub for its community. It has an emergency room, several kinds of clinics, physical therapy and rehabilitation services. It has 25 beds or fewer but only four beds have acutely ill patients in them on a typical day. There may be a few more patients recuperating. Most such hospitals have no specialized facilities like intensive care. They don't ordinarily keep patients with life-and-death illness.

Researchers at the Harvard School of Public Health, writing in the Journal of the American Medical Association, reported that between 2002 and 2010 a gap in survival developed between patients in these critical access hospitals and large medical centers. Specifically, death rates for people with heart attacks, pneumonia or heart failure in large, full-service hospitals have improved while survival chances have gotten a little worse in critical access hospitals. Patients with heart attack, pneumonia or heart failure are 1.8% more likely to die if they are hospitalized in a critical access hospital than in a large, full-service hospital. 

The Harvard researchers argued that the mortality rate of critical access hospitals was higher because these hospitals aren't under the same pressure to improve as larger hospitals. Here is their logic: Medicare keeps statistics on deaths at large hospitals for patients being treated for heart attacks, pneumonia or heart failure. But Medicare doesn’t track these death statistics for critical access hospitals. Since they aren’t getting measured, the argument goes, critical access hospitals don’t perform as well.

But the Harvard group failed to understand how patients, families, critical access hospitals and regional medical centers interact.

Large urban hospitals, the "medical Meccas" have intensive care units and cardiac catheterization laboratories – highly specialized facilities that can be both lifesaving and terrifying. The noise, sleep deprivation and medication very commonly cause patients, particularly sick, old people, to lose their minds temporarily. It must be terrifying. Small, rural hospitals lack intensive care units and cardiac catheterization labs, but they have familiar surroundings and nearness to home and family. They are somewhat less likely to save your life and to make you temporarily crazy. Different people value these factors differently.

Rural Assistance Center, HHS dataMap shows the location of critical access hospitals as of second quarter 2011. (Larger version.)

Medicare's "standard of care" calls for a patient with a heart attack to get from the door of a hospital to the cardiac catheterization lab within 1.5 hours. If a person shows up at a critical access hospital emergency room with symptoms of a heart attack, the emphasis will be on making the diagnosis and arranging a speedy transfer to the regional medical center with its cardiac catheterization facilities. The patient with the developing heart attack probably won't be admitted to the critical access hospital at all.

That patient will only be kept in the critical access hospital if he or she refuses to be sent to the medical center. This might be because they want to stay near home and family, even if they can't have the high-tech intervention of the medical center. Perhaps they have already had all the cardiac intervention possible, or for some other personal reason have made the decision to stay in their home community.

The same pattern applies in cases of pneumonia, heart failure and all the other life-threatening catastrophes that happen to people. If recovery is likely with basic medical and nursing care in supportive surroundings, the small community hospital is the best and most economical place to be cared for. In a life-and-death situation, for a person who wants the best chance of survival if not comfort, the large, regional hospital is the best bet.

USA Today was among the national media that ran the report on research that found a "survivability gap" between urban and rural hospitals.On the other hand, if it sounds as if the patient is likely to die even with intensive care, the large medical center is likely to resist taking him and risk getting a bad mark on the hospital’s statistics.

What has changed over the past decade is the development of patient movement arrangements among ambulance services, rural hospitals and emergency rooms and regional medical centers. These arrangements should, and usually do, result in patients who can benefit from the high-tech facilities of the regional medical centers getting there quickly. 

The patients in the small rural hospital with heart attack, heart failure or pneumonia have become a select population. A large proportion has decided that they are through paying all the human costs of the miracles of modern medicine. They have made the decision to stay in familiar surroundings near home and family. 

The researchers found that 13.3% of the patients at critical access hospitals with one of the three conditions died, compared to 11.4 % of the medical center patients. Given all the terrible tools that modern medical centers have to work with, I’m amazed they only manage a small difference in patient survival over the most basic, little country hospitals in America. 

The more important issue is to be certain that the wishes and needs of the patients have been thought through carefully and deliberately. This has to be done before the emergency arises. Can Momma or her daughter say with confidence whether she wants to be taken to Saint Metropolous or stay in Localsville? If her hospitalization is guided by that choice, it will reflect "patient centered care" as recommended by the Institute of Medicine.

Imagine how the headlines would have read if the research results had shown no difference in survival between the 25-bed critical access hospital and the 600-bed "medical Mecca":  "Billions spent on intensive care units show no survival advantage!" Now that would have been news.

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000 and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine.

Comments

Close to home

All my great grandparents died at home. Half my grandparents died that way, the other half in nursing homes or hospitals. These days no one dies any other death at home than sudden. As we live longer we also live our final days farther from home. Its too bad that so many of us decline having the conversation about end of life. Like our old friend and country doctor "Mac" Marvin Mcdonald told my apprehensive Mother before I arrived, "there are millions of people in the world and all of 'em were born". As I near my seventh decade on earth, Dr Mac might also point out that all of us are also headed eventually for demise. We should talk more about "how" without the totally inapplicable "if". Equally important as "how" in my opinion, is "where".