HOSPITAL RANKINGS: Teaching Facilities Shine, but Why?

      Heart attack patients admitted to hospitals that top the charts on U.S. News and World Report's annual "America's Best Hospitals" list fared better than other patients, largely because they were administered a low-tech treatment that could easily be duplicated at smaller hospitals, according to a study in today's New England Journal of Medicine. Jersey Chen and colleagues at the Yale University School of Medicine noted that the yearly hospital "report cards ... [have] been described as a public relations gold mine for top-ranked hospitals," but recent examinations "have identified a number of methodologic weaknesses in the selection of top-ranked hospitals." In an effort to determine whether a top ranking was "explained by better performance on clinically derived (rather than reputation-based) measures," the researchers examined the treatments given to heart attack patients at hospitals of varying status. The researchers tracked nearly 150,000 Medicare beneficiaries hospitalized in top ranked hospitals -- all of which were teaching hospitals -- similarly equipped but lower ranked hospitals and non-similarly equipped hospitals -- mostly rural or community hospitals -- during 1994 and 1995. The risk- adjusted patient mortality after 30 days at the top ranked hospitals was 15.6%, compared to 18.3% at similarly equipped hospitals and 18.6% at less sophisticated hospitals. However, the researchers found that the "survival advantage associated with admission to top-ranked hospitals appears to be more strongly related to the rates of aspirin and beta-blockers," a relatively unsophisticated and inexpensive treatment. Among the top ranked hospitals, 96.2% of patients considered candidates for use of aspirin were treated with the drug. However, the rate was 88.6% for similarly equipped hospitals and 83.4% at the remaining facilities. The use of beta blockers followed a similar trend, with 75% of candidates at top ranked hospitals receiving the drugs, compared with 61.8% of similar facilities and 58.7% of the remaining hospitals.

Applications
      The authors concluded that admission to one of "America's Best Hospitals" was associated with lower short term mortality, but they caution that "it does not necessarily confirm the ranking method used to generate this list" (Chen et al., New England Journal of Medicine, 1/28 issue). Health officials zeroed in on the cost effectiveness of the treatment, noting that the technique "could be duplicated in small, rural hospitals" that lack the technology of the larger, higher-ranked facilities. American Heart Association President Valentin Fuster applauded the results, saying, "The hospitals that have less (patient) volume, less technology, they should be able to follow these guidelines. This is simple, cheap" (Johnson, AP/Philadelphia Inquirer, 1/28).

Life and Death Decisions
      In a separate study in the same issue of the NEJM, Dr. Donald Taylor and his colleagues at Duke University found that although admission to teaching hospitals was associated with higher costs for Medicare patients, their survival rates were better than at other hospitals. Using data from the National Long Term Care Survey of Medicare beneficiaries who were admitted to hospitals between 1984 and 1994 for the treatment of hip fracture, stroke, coronary heart disease or congestive heart failure, researchers assessed the survival rates of patients initially treated at five types of hospitals: major teaching, minor teaching, government-run, for-profit and nonprofit (Taylor et al., 1/28 issue). "Basically what we found is that, not surprisingly, major teaching hospitals, primarily those located at universities, cost the Medicare program more than non-teaching hospitals do," said Taylor, "[b]ut we did find evidence that such teaching hospitals did deliver better results." Indeed, the researchers found that major teaching hospitals "had the highest crude survival for hip fractures, stroke, and congestive heart failure, and were second to minor teaching hospitals for coronary heart disease." In addition, the mortality rate of patients treated at the major teaching facilities was 25% below that of for-profit, non-teaching hospitals (Duke release, 1/28). The authors concede that the "debate about whether the teaching hospitals receive for graduate medical education and disproportionate-sharing payments" is justified. They conclude that "ending such subsidies and payments would reduce total Medicare payments at six months by less than 5% for patients" with the four conditions. They conclude, however, that the "overall improvement in long term survival after each treatment for these conditions at major teaching hospitals is a social benefit worth considering" (NEJM, 1/28 issue).

Hanging in the Balance
      In an accompanying editorial, NEJM editor-in-chief Dr. Jerome Kassirer concludes, "The studies in this issue of the Journal and elsewhere show that improving the quality of care in nonteaching hospitals does not necessarily require more equipment or even more specialists. Simply giving the right drug ... can mean the difference between suffering and health, life and death" (1/28 issue).