Op-Ed

How to choose a hospital (spoiler: it’s not getting any easier)

At some point, almost all of us will seek treatment at a hospital. And it is hard to decide which one to choose. Do not expect an unbiased opinion from your health-care provider, since most are now employees of the facility.

To find the best care, you must shop for both quality and price. If your hospital admission is planned, it is best to negotiate payment on the front end.

Do not expect accrediting agencies to assure hospital quality. Currently, the U.S. Congress is holding hearings because 39 percent of hospital accreditation surveys did not detect serious problems. Thus, you need to do your own research.

Four rating agencies can be used: The Leapfrog Group, Consumer Union and Hospital Compare provide information regarding patient safety. U.S. News & World Report focuses on the ability to handle complex cases. Much of this data has been criticized because it is not independently verified.

Reputation comprises 24.5 percent to 27.5 percent of USN&WR’s total score, and I have received letters from institutions encouraging me to vote. USN&WR also adjusts for patients’ socioeconomic status. Many advocates feel that this may allow for the normalization of inadequate resources being provided to hospitals that serve the poor, in other words, making poor care appear better than it is.

Overall, Lexington hospitals have good quality and are outperforming the institutions in Louisville.

Consistent with my previous op-eds, the University of Louisville is still struggling to improve its rankings. And as expected, large teaching institutions are ranked higher by USN&WR.

Hospital-acquired infections are another important consideration. Information can be found for severe MRSA infections involving the bloodstream and for the dangerous gastrointestinal infections caused by C. difficile, along with infections resulting from a number of procedures. Different strategies are needed to prevent different types of infections. Thus, it is not uncommon to be good at controlling one type, but not another. Most infections are reported using a standardized infection ratio (SIR) which is a mathematically adjusted number used to compare infections — a number that one consumer advocate, Raye, described as “intended to obfuscate the facts for all but those with privilege.”

The United States has missed the majority of its goals in controlling infections and we are not on track for a 50 percent reduction in MRSA bloodstream infections by 2020. Thus, even average performance should be viewed as an unacceptably high level of infections.

Overall, Kentucky needs improvement regarding hospital-acquired infections. If one looks at the absolute number of cases of MRSA bloodstream infections, out of 3,819 hospitals, the University of Kentucky and Norton Hospital are the seventh- and sixth-highest in the nation.

For UK, this number is mitigated after risk adjustment. Mathematically, these rates are lowered for number of beds, being a teaching institution and if there are high rates of MRSA in the community. The latter does not make much sense to me. If the community has a high rate of MRSA, then patients should be screened, and carriers isolated and decolonized before an infection develops. This strategy has dramatically reduced rates of MRSA infections in Veterans Administration Hospitals and the United Kingdom.

Health-care worker hand-washing is also extremely important, but should be viewed as a backup measure, since these organisms should not be on the hands in the first place. Handwashing alone will not reverse the tide of this dangerous epidemic.

Despite struggling with the control of MRSA, UK and many hospitals are doing an outstanding job preventing C. difficile infections. The primary mode of prevention is not prescribing antibiotics which can activate sleeping C. difficile spores. Infection rates involving large treatment catheters which are placed deep into the body (central-line associated bloodstream infection) are also very important. These rates are also adjusted, but many advocates think the vast majority are preventable and a facility’s absolute number should be in the low single digits. Facilities with high rates should take a cue from the airline industry and require the use of a checklist to make sure protocols are followed consistently.

Most Kentucky hospitals do not have an infection rate available for abdominal hysterectomies. I hope this is because vaginal hysterectomies and not dangerous procedures using morcellation are being performed. Of the hospitals for which information is available, all had less than five infections with the exception of Norton Hospital in Louisville which had a worse than expected infection rate, with 24 cases.

The vast majority of patients who seek care in Kentucky’s hospitals have excellent results. However, if you suffer an adverse event, the incidence for you is 100 percent. As stated by Jim Conway, past senior vice president of the Institute for Healthcare Improvement, “In the gap between excellence and perfection, there is suffering, harm, tragedy, and death.”

Hospitals can and must do better.

Kevin Kavanagh of Somerset is a retired physician and board chairman of Health Watch USA.

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