Cedars-Sinai Medical Center in Los Angeles took a more aggressive approach to end-of-life care, according to Dartmouth Medical School's Atlas project report. (Photo: Nick Ut, AP)
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
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.
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
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
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." (See
Table 1 below)
While he can only "look at behavior and can't
predict motivation," Goodman says some hospitals may have a lot of
capacity in their intensive care units and not enough in primary care.
"With such drastic variations from one institution to the next, they clearly cannot all be right," says Goodman.
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."
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.
says the Dartmouth report can be valuable for both medical students and
patients, but he notes that the Atlas Project's research is sometimes
considered "practically a bible," while others think "it's wrongheaded."
Any measures of "quality of care" in hospitals, however, vary widely
and the subject is "really, really controversial," he says.
TABLE 1: Variation in end-of-life care and management of chronic illness
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
Source: Dartmouth Medical School's Atlas Project