November 01, 2007

The Truth About Hospitals

In a bold move intended to foster quality care, the Massachusetts Hospital Association has begun posting data on its web site about the risks patients face if they are hospitalized,. Specifically, it reports on falls, on falls which cause injury, on surgical infections, and on the care for several conditions, including pneumonia, heart failure, and a heart attack. The new site is called Patients First ( and it is intended to “educate people so they can make better decisions,” accorded to the senior vice president of the Institute for Health Improvement, which helped develop the new approach. Will this strategy in fact help patients decide where to seek their care? Is it a good idea?

It’s hard to imagine a patient in the throes of a heart attack checking out the web site to see which hospital in his area performs best. Odds are that the ambulance will take him to the nearest facility, regardless of his preferences. Moreover, most patients choose a physician, not a hospital, and accept that they will be hospitalized at whatever facility their physician practices.

Even if an individual patient did consult the web site to learn more about the hospital where his doctor worked, he would be hard pressed to draw any useful conclusions from the data presented. Take falls as an example. If you look up the hospital where I care for patients, the Brigham and Women’s Hospital, (BWH) you will find two different graphs, one showing the number of falls per 1000 patient-days, the other showing the number of falls with injuries per 1000 patient-days. In each category, you will find a rate for the medical floors, one for the intensive care units, another for combined medical-surgical units, a rate for step-down units, and still another rate for exclusively surgical floors. And for each location, you will see the BWH rate over a 6-month period compared to the “peer group average.”

I wanted to know how likely my patients are to fall and get hurt if they are on a medical floor at the BWH. What I learned is that the hospital has 0.96 injurious falls/1000 patient-days compared to the peer group average of 0.76. Presumably this means that the BWH is worse than average. But how much worse? Are the rates significantly different? Are the patients at the BWH comparable to the patients cared for in the “peer group” hospitals? What is the peer group anyway?

To get the answers to all these questions, you need to go to the Appendix, a 67 page document (also available on line) that describes the methodology on which the numbers are based. Hospitals are grouped according to size, so the BWH is lumped with all hospitals in Massachusetts having over 500 beds. That means Boston Medical Center, Massachusetts General Hospital, the Beth Israel Deaconess Medical Center, and the University of Massachusetts Medical Center. You can also find the confidence intervals for the rates reported, the statistical measure you need in order to figure out whether a given facility’s rate is significantly different from the rates at the other facilities. What you learn is that in fact, there is no significant difference between the BWH rate and the peer group average. In fact, if you look up the data for each of the hospitals with more than 500 beds, you will find that they all have equivalent rates, except Boston Medical Center, which does a bit less well.

What is also buried in the appendix is that that the fall rate of 0.96/1000 patient-days on the medical units at the BWH is based on a grand total of 2 falls that occurred in 2084 patient days. I wouldn’t want to draw any inferences based on 2 cases.

You might conclude that I don’t think much of this idea of publicly displaying data relating to quality of care. Actually, I think it’s an excellent idea, but not because it will help patients make choices. It’s a good idea because hospitals compete with each other and knowing how your neighbor is doing will stimulate you to do better. Above all, it’s a good idea because it helps hold hospitals accountable for the care they give and it encourages each facility to compete with itself to do better.

Of all the hospitals whose performance data is reported, I noticed only one that posted a comment about its own statistics. The Beth Israel Deaconess Hospital in Boston went beyond the numbers to say that starting in May, 2007 they developed and implemented an enhanced program for identifying patients at risk of falling. Their study teams discovered that the middle of the night is a particularly risky time. They responded to this observation by instituting a program of frequent checks at night. They also found that patients often fall when left unattended in the bathroom and have made efforts to ensure that high risk patients are not unsupervised in the bathroom.

This is exactly how hospitals should be responding to data. The BIDMC, it turns out, is way ahead of the curve. Spearheaded by its president, Paul Levy, the hospital has its own web site for reporting data. Called “Putting Ourselves Under a Microscope,” this site reports data on many of the same indicators as the Massachusetts Hospital Association. (

The BIDMC compares its performance to a national average and to its own previous performance. And it sets targets for improvement, with a plan for how to achieve the targets. Now that’s impressive.

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