Making informed health-care choices amidst a sea of statistics
Back in the day when someone got seriously ill or injured, a trip to the emergency room rarely elicited thoughts of safety or added risk. The notion of acquiring a new condition didn’t cross people’s minds. If hospital wards looked clean and sterile, no red flags were raised.
Then, over the past few years, came headlines and newscasts with terms like “MRSA” or “medication error.” Suddenly, more and more people began to worry about their medical centers. Accumulations of statistics further transformed hospital patients into health-care shoppers.
Resources for comparisons grow ever more abundant. Publications such as Consumer Reports and U.S. News & World Report compose rankings. The U.S. Department of Health and Human Services offers “Hospital Compare,” a web-based feature with data compiled through Medicare. The California Department of Public Health (CPDH) tracks infection rates and regulation violations.
That’s a lot of information—much of it statistical—which brings to mind a classic quip from Mark Twain: “There are three kinds of lies: lies, damned lies, and statistics.”
Mike Wiltermood, president/CEO of Enloe Medical Center, is fond of this quotation. It’s not because he wishes his hospital wasn’t open to scrutiny; rather, it’s because health statistics can have so many asterisks, modifiers and caveats that using numbers alone as the basis for evaluating safety and performance can prove more confusing than enlightening.
“Sometimes where the statistics are misleading is where documentation becomes an issue,” Wiltermood said in a recent interview at Enloe. “We’ve been finding that because of the way the reports have been made, if we don’t code everything properly, hospitals can look bad when we’re actually doing a pretty good job.
“I spoke to a few administrators back east, and one in particular said that on risk-adjusted-outcomes data [i.e. ratings that take into account the severity of cases a hospital treats], ‘We were in the middle of the pack until we improved our documentation; now we’re in the top 10 percent. Same doctors, same nurses, same procedures, same care.’”
The devil is in the details—or, in this case, the documents.
California has some of the most stringent laws in the nation related to the reporting of specific health-care data.
“Our advice usually is for people to use not only our [online] tools but also the federal tools available and reliable sources like Consumers Union, and come to their own conclusion,” CDPH spokesman Ralph Montano said by phone from Sacramento. “There are over 450 hospitals in the state of California, and we have information for all of them, but how much weight you give information is up to you.”
That’s great for someone with a medical degree; what about the average Californian?
Montano suggests keeping in mind the type of facility. Comparing a rural hospital to a trauma center is like comparing a cherry to a grapefruit, as larger hospitals perform more complex and risky procedures on patients in more serious or critical condition. In fact, smaller hospitals transfer severely afflicted patients to a trauma center or university hospital precisely because those are places where such treatment is possible.
“A facility can’t do those sorts of procedures without risk involved,” Montano explained. Operate on the gastroenterological system and “the rate of infection is high because of where you are in the body.” The stomach, intestines and colon contain thousands of bacteria associated with digestion.
That’s why some statistical measures are risk-adjusted, or expressed as per-capita figures based on the number of patients or total days in the hospital. Comparing hospitals across the country brings another set of challenges because different states have different standards and regulations regarding levels of reporting.
“Facts are stubborn, but statistics are more pliable.” That’s more wisdom from Mark Twain, and it certainly seems to apply to health-care reports.
Take the case of Clostridium difficile infection (also known as C. diff, or CDI). This condition comes from a bacterium that, with prolonged use of antibiotics, can cause diarrhea, colitis and other intestinal ailments.
People can walk into the hospital with C. diff inside them. Sometimes it activates; often it doesn’t. The timing of testing for C. diff—on intake, or during hospitalization—can determine whether an infection can be classified as community-acquired or hospital-acquired. That means hospital’s CDI rate can rise or fall based on when the test was administered, not on any improvement or decline in the quality of care.
C. diff holds particular interest for California health-care providers because it’s one of the infections tracked by state public-health officials. CDPH also charts bloodstream infections from MRSA (methicillin-resistant Staphyloccocus aureus), a staph bacterium that survives certain antibiotic regimens.
MRSA can be life-threatening. “People are really worried about it,” Wiltermood said. “But there is a community-acquired rate in Butte County of about 5 percent, and now 50 percent of staph infections are resistant to methicillin, so if you’ve got staph, you’ve got a 50-50 chance that it’s MRSA.”
Until recently, before advances in medicine yielded faster screening, a MRSA test took 24-48 hours.
“If a patient exhibited symptoms during the course of their stay, we couldn’t definitively say they didn’t get it here,” Wiltermood explained, “so in order to be honest about the reporting, we were saying it was hospital-acquired when they could have brought it in with them.
“We had a little bit higher rate we were reporting—it wasn’t huge, but it was higher. Now that we’ve got a two-hour rapid screen that we give to our high-risk patients, our MRSA rate has gone through the floor.
“Because it’s publicly reported data, we’re spending more money up front even though it doesn’t necessarily change the course of treatment, doesn’t necessarily change anything for the patient; we’re doing it just for the numbers.”
Enloe is certainly not alone in facing these pressures. Reimbursements linked to performance put value on stats beyond marketing and public relations.
There’s a balance.
“I think that the publicly reported data is one of the more costly and time-consuming changes that has come out of the health-reform movement,” said Dr. Marcia Nelson, vice president of medical affairs at Enloe. “But the transparency and accountability that comes with sharing our performance has really raised the bar and made people aware that we really need to be looking all the time to improve care.”