Quality of Heath Care Varies by Region According to Study

story first appeared on usatoday.com

Where you live – and where your doctors did their training – has a lot to do with whether you'll be operated on, get an infection or have other potentially risky medical tests, a report out Tuesday said.

And we're not talking about small-town vs. big-city medicine. The report by Dartmouth Medical School's Atlas Project looked closely at 23 medical centers, including many of the top-rated hospitals for clinical excellence by U.S. News and World Report and other leading hospitals affiliated with universities. New Atlas data that include nearly all the teaching hospitals in the U.S. were also released.

The study was done to help medical students decide where to do their residencies, but it also helps consumers better understand how their local hospitals differ from the norm.

Among the findings: If you're in Salt Lake City, you're twice as likely to get knee-replacement surgery than if you're in New York City. Lubbock, Texas, had the highest rate of knee replacements -- 13.2 per 1,000 Medicare beneficiaries.

Arthritis in the knee is "not a dependably progressive disorder" that nearly always requires surgery, says David Goodman, a doctor who is co-principal investigator for the Atlas Project.

The report uses new 2010 Medicare data to update previous reports on regional variations in the treatment of patients at the end of life, trends in surgical procedures and trends in quality of care as it relates to patient experience and safety.

There is an emphasis on more aggressive treatment over preventive care at some hospitals, Goodman says. The report includes a "hospital care intensity index" when it comes to treatment of people at the "end of life."

Goodman says some hospitals may have a lot of capacity in their intensive care units and not enough in primary care.

Patients at NYU Langone Medical Center were 47 times less likely to get an infection from a urinary catheter than patients at the University of Michigan Health System, for example. Mount Sinai Medical Center had the second lowest. Goodman says such infections are "largely preventable."

David Muller, dean for medical education at the Mount Sinai School of Medicine, says the population of patients a hospital treats -- that is, whether they are low income and already in poor health -- can have a lot to do with whether a patient contracts an infection and can recover fully from it. The report's rates were adjusted for age, race and gender using the U.S. Medicare population as the standard.

Muller says the Dartmouth report can be valuable for both medical students and patients, but he notes that the Atlas Project's research is sometimes practically considered a bible, but he says any measures of quality of care in hospitals, varies widely and the subject is controversial.

This list ranks 23 teaching hospitals by the Hospital Care Intensity (HCI) index, which is a measure that combines the number of days patients spent in the hospital and the average number of inpatient physician visits during the last two years of life.

Hospital (ranked by Hospital Care Intensity (HCI) index):

• Cedars-Sinai Medical Center 2.06
• NYU Langone Medical Center 1.73
• Mount Sinai Medical Center 1.50
• Ronald Reagan UCLA Medical Center 1.48
• New York-Presbyterian Hospital 1.37
• University of Pittsburgh Medical Center 1.28
• Northwestern Memorial Hospital 1.28
• Massachusetts General Hospital 1.19
• Cleveland Clinic 1.12
• Hospital of the Univ. of Pennsylvania 1.08
• University of Michigan Health System 1.07
• Brigham and Women's Hospital 1.06
• Johns Hopkins Hospital 1.01
• United States average 1.00
• Indiana Univ. Health (Clarian Health) 0.96
• Barnes-Jewish Hospital/Washington Univ. 0.95
• UCSF Medical Center 0.92
• Duke University Medical Center 0.87
• Vanderbilt Univ. Medical Center 0.80
• University of Washington Medical Center 0.78
• Stanford Hospital and Clinics 0.78
• St. Mary's Hospital, Mayo Clinic 0.70
• Scott & White Memorial Hospital 0.62
• University of Utah Health Care 0.62

Less Invasive Surgery Procedures

 First appeared on Chron.com
Dr. Sandra Hurtado moved her right hand, ever so slightly, and a kidney appeared on the screen.

"Keep coming," surgical robotics instructor Armando Garcia urged. "Keep coming ... Now, go right above it with your left hand."

Hurtado, an ob-gyn, has performed laparoscopic surgeries since leaving medical school more than 20 years ago. But last week, she was at Memorial Hermann Hospital's surgical training lab to gain skills in a movement that has sharply reduced the demand for traditional surgical procedures.

Despite resistance from some peers, Hurtado and other midcareer surgeons are scrambling to keep pace with the growth in less-invasive surgical techniques, allowing them to satisfy patients' demands for smaller scars and quicker recoveries.

Young surgeons learn the procedures during training, but Dr. Daniel Albo, chief of surgical oncology at Baylor College of Medicine, said some older surgeons still resist.

"There's an ego that gets in the way of a surgeon saying, 'I need to get back and retrain,' " Albo said. "Laparoscopic surgery requires a completely different skill set.

"Think of it as grandpa versus the grandson playing video games," he said. "For the grandson, it is very intuitive. For the grandpa, it's an aggravation."

Cost factor unclear

There aren't definitive statistics for how many of the 27 million surgical procedures performed in the United States every year are done with minimally invasive techniques or how much money that saves.

Some people question the conventional wisdom that the new techniques save money, since the up-front costs can be high. But that hasn't slowed the rush toward the new procedures.

The revolution started in France in 1987, when a gynecologist used a video monitor and specialized instruments to remove a patient's gallbladder through small incisions, rather than the traditional hip-to-hip cut across the abdomen.

Similar procedures had been done before, but that procedure in Lyons, France, is considered the true beginning of minimally invasive surgery. Now, it's the standard way to remove a gallbladder.

Colorectal surgeries, at the other extreme, are still done almost exclusively via a large incision, Albo said.

Minimally invasive surgery includes a variety of techniques: Cardiologists use stents as an alternative to chest-cracking coronary bypasses. Surgeons use endoscopes, inserted through the mouth or another body opening, for some procedures. Laparoscopic procedures use special tools inserted through one or more small incisions.

A tiny camera is slipped inside the body to display the view on a video screen, since the surgeon can't see the internal organs directly.

Challenge for veterans

The techniques require a shift in mindset, said Dr. Shawn Tsuda, chief of the division of minimally invasive and bariatric surgery at the University of Nevada Medical School.

"You're looking at a two-dimensional screen instead of the patient's body and tissues," he said. "For the young generation, maybe they play video games or punch in texts on their tiny phones. They're good at it.

"For more experienced surgeons, it can be a real challenge."

From bariatric surgery to breast augmentation surgery, robot-assisted surgeries are the next frontier.

The video display is three-dimensional, and Hurtado said the tools offer more dexterity than those used in traditional laparoscopic surgery.

She and her Obstetrical & Gynecological Associates colleagues at the Woman's Hospital of Texas already perform mostly minimally invasive procedures, but some patients still require more extensive open surgery, she said.

Last week she was learning to use robot-assisted tools, which she said will reduce the need for that.

Patients like the smaller incisions and faster recovery. Erik Wilson, a surgeon and faculty member at the University of Texas Medical School at Houston, said patients always ask for minimally invasive procedures.

"That's where everything is going because that's what everyone wants," said Wilson, a founding member of the Clinical Robotic Surgery Association. "I don't open people up for anything unless they're critically ill and you just don't have any time."

Financial edge?

There is less agreement on the financial advantages. Initial costs increase to pay for the new surgical tools, Tsuda said.

Robot-assisted surgery has especially high startup costs; Peter Herrera, director of surgical innovation at Memorial Hermann, said each station and its accompanying tools cost $1.5 million or more.

But most patients leave the hospital sooner than those who undergo traditional surgery.

They also have fewer complications and return to work more quickly, all of which can reduce costs over time.

"If you look at global health care costs, the cost of not only the procedure itself, but of complications, the cost of managing complications, recovery times, return to work times, then laparoscopic surgery reduces the cost of care," Albo said.