At a recent conference, Harvard surgeon and best-selling author Atul Gawande told the audience of health professionals and policy makers that he always assigns his medical students a book about baseball called Moneyball: The Art of Winning an Unfair Game. It's the story of how the 2002 Oakland Athletics, which had one of the lowest payrolls in professional baseball, were able to consistently out-compete better financed teams due to their general manager's unrivaled ability to evaluate and appropriately value players. Oakland took advantage of the tendency of other teams to overvalue players based on word-of-mouth assessments of talent or commonly measured statistics—such as batting averages and number of stolen bases—that had little relationship to winning games.
Gawande's point was that many of the Moneyball lessons can be applied to medical care when it comes to evaluating the performance of doctors and hospitals. Since I have a policy of not accepting close friends and family members as patients, I refer them to doctors with whom I've worked in the past or have met through medical conferences. My loved ones may be reassured by my recommendation, and I assume I'm pointing them to a good doctor. But I also have a nagging worry that my gut instincts about a doctor I'm acquainted with may not correlate with the quality of care that doctor provides. I have no way of knowing if my friends and family members will get better or worse care from my referral than if they had randomly selected a name from a list. In fact, a recent study published in the journal Archives of Internal Medicine found that publicly available data on physicians such as medical school attended, malpractice lawsuit history, and specialty board certification are poor predictors of their adherence to accepted standards of medical care such as checking cholesterol levels in patients with diabetes and performing Pap smears in adult women at least every 3 years.
Take the well-known U.S. News & World Report "Best Hospital" Rankings. Whether a hospital is ranked in a particular specialty depends on its score, almost a third of which comes from its reputation with specialists. There may be a good argument for doing that, but to me it's too much like my physician recommendations. The website of the federal Centers for Medicare and Medicaid Services features a Hospital Compare tool that allows patients to search for and compare up to three hospitals at a time based on statistics such as the percentage of patients with heart failure who receive appropriate discharge instructions, medications, and smoking cessation counseling. It tells you if readmission and death rates for patients with heart attacks, heart failure, or pneumonia are better, the same as, or worse than the national average. (Higher rates of readmission could indicate that the hospital didn't do a good job of treating the patient in the first place or provided inadequate instructions for follow-up care.) It also provides subjective measures like patient surveys about the responsiveness of nurses and doctors, the cleanliness of rooms and bathrooms, and how well pain was controlled.
The Society of Thoracic Surgeons recently allowed Consumer Reports to use its national database of information about heart bypass surgeries to rate surgical groups on patient survival rates, surgical complications, and medication management. But this ranking, too, has its limitations: While about 90 percent of the approximately 1,100 cardiac surgical groups in the U.S. participate in the society's database, just 22 percent of these groups opted to include themselves in the Consumer Reports rankings. That's because they didn't want their performance data to become public. And none would allow individual surgeons to be named.
Many health insurers have begun sending confidential "report cards" to family doctors that give them feedback on their performance in managing chronic conditions such as heart failure and diabetes. These evaluations, too, have been criticized for ignoring differences in patient populations; younger patients with high-paying jobs, for example, are less likely to stop taking medications for financial reasons than older patients on fixed incomes. So a doctor with a poorer patient population might get poorer grades than one with a richer population. Still, the evaluations might be helpful in comparing two doctors who practice in the same neighborhood, if practices eventually make this information public to prospective and current patients.
In the next few years, more information should become available on the quality of care provided to patients. The government is working to compile national numbers on hospital complication rates, which would add to patient safety data already being collected such as how often incisions reopen after surgery. The new data that will soon be offered on the Hospital Compare tool will, in my opinion, be a game changer. First and foremost, it will include information on infection rates. Nearly 90,000 U.S. patients die every year from hospital-acquired infections, and about a third of those deaths are due to preventable bloodstream infections caused by the insertion of a catheter, according to the Centers for Disease Control and Prevention.
It would be nice to know how often the hospital you pick for surgery takes precautions proven to prevent these infections, like covering patients with sterile drapes and swabbing their skin with an antiseptic before a catheter is inserted and making sure doctors who do the insertion wash their hands and wear a sterile mask, hat, gown and gloves. Hospital Compare will also provide data on surgical mistakes due to foreign objects left in the body; severe pressure ulcers from not turning bed-ridden patients, falls and other accidents that occur in the hospital; blood transfusions with the wrong blood type; and signs of diabetes mismanagement.
As more reliable statistics about the quality of care provided by doctors and hospitals become available, it's important to consider what factors matter most to you as a patient. For example, clean bathrooms are nice, but most people would place a higher value on surviving the hospitalization and not needing to return after being discharged. A heart surgeon's brusque bedside manner may not matter nearly as much to you as the percentage of her patients who develop postoperative infections. And family doctors who are willing to share their numbers—and work to improve them—are likely to go the extra mile to manage your chronic condition appropriately.