Good Help, Close to Home
Do-it-yourself project. 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.
EXPERIENCE COUNTS
The south Texas border town of McAllen does a brisk business in heart surgery. Surgeons at McAllen Medical Center performed just over 800 bypass operations in 2003--fifth highest in the state--and did them well. The mortality rate, adjusted for the severity of patients' conditions, was 1.2 percent, less than one-third the state average of 4 percent. "I do a better job on these patients in my community hospital than I did when I was training in my university hospital," says McAllen's Lester Dyke, a cardiac surgeon who does between 500 and 600 of the procedures a year and cites a mortality rate of about 1 percent.
advertisement
