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Best Hospitals 2006


Why Large Teaching Hospitals Really Are the Best

One physician makes the case.
By Sandeep Jauhar

Which are the best hospitals in New York? According to the 1,000-plus New York–area doctors in New York Magazine’s inaugural survey on the subject, they’re generally large teaching institutions—sprawling multi-campus behemoths like New York–Presbyterian Hospital (the No. 1 Overall Best Hospital), Mount Sinai Medical Center (No. 2), and NYU Medical Center (yes, No. 3) that treat hundreds of thousands of patients a year. While I didn’t participate in the survey, I suspect my vote would have gone the same way. After training at two of the largest academic institutions in Manhattan, I’ve come to believe that big teaching hospitals are the best places to go when you’re sick. Based on these survey results, I’m hardly the only doctor who has this bias. But are we right?

On the evidence, it looks like we are. Two recent studies showed that patients treated for several common medical disorders fared better at teaching hospitals. In a 2002 study in The American Journal of Medicine, researchers analyzed a database of almost 400,000 patients admitted with heart failure, heart attack, or stroke to 248 hospitals around New York State. In-hospital death rates for all three conditions were much lower at major teaching hospitals than nonteaching institutions. What’s more, a study of hip fractures, stroke, coronary heart disease, and congestive heart failure published in The New England Journal of Medicine found that the care at major teaching hospitals was costlier but led to better overall survival, especially for those with hip fractures.

Why do major teaching hospitals produce better outcomes? Aren’t they known for delivering hopelessly impersonal, data-driven care from a revolving door of Scrubs wannabes? Sure. But that might not be a bad thing. While throngs of interns and residents may be annoying when you’re reciting the details of your fainting episode for the third time in the middle of the night—“So, tell me what happened”—all those eyes on each patient means things don’t get overlooked. Up to 80 percent of medical diagnoses can probably be made on the basis of a patient’s history, and the more people interrogating you, the more likely we are to get it right.

Big teaching hospitals also conduct topflight research, basic and clinical. With certain diseases, especially cancer, your best hope may lie with an experimental drug protocol, and the pace of innovation is so fast today that hospitals involved in the latest trials might just stand a better chance of saving your life. At the survey’s top-ranked cancer hospital, Memorial Sloan-Kettering Cancer Center, virtually every patient just diagnosed with cancer is offered the chance to participate in a study.

Another Big Medicine advantage? Volume. It may sound obvious, but would you rather have your arteries Roto-rootered by a cardiologist who does 200 angioplasties a year—or 20? A busy surgeon, research suggests, may, in fact, be a better one: A paper published in April 2002 in The New England Journal of Medicine examined statistics on 2.5 million operations between 1994 and 1999 and found that mortality decreased as volume increased for fourteen surgical procedures. With coronary-artery bypass surgery, the authors concluded that 314 deaths per year could be avoided in the United States if very-low-volume hospitals had the same operative mortality as very-high-volume hospitals.

A surprising amount of the time, big hospitals’ better outcomes are about nothing more exciting than good old-fashioned blocking and tackling. You’d be amazed how well a hospital can do simply by paying scrupulous attention to basic patient care and doing things in ways that have been proved to work.

That’s certainly true in my hospital system, one of the largest in the country (and one that counts two facilities, Long Island Jewish Medical Center and North Shore University Hospital, I’m happy to say, in the survey’s overall top ten). We meet each month to critique our own performance on certain “core” quality indicators: hospital-acquired infections, delays in administering antibiotics for pneumonia, “door to balloon” time in the cardiac catheterization lab, and the like. We discuss troubling statistics, such as that only about two-thirds of patients nationwide receive beta-blocker therapy after a heart attack, and roughly the same percentage receive ACE-inhibitor therapy after a diagnosis of heart failure, even though both treatments have been shown to prolong life. My hospital has even hired nurses to independently review patients’ charts to ensure that they’re receiving established therapies.

In the best academic hospitals, schooling doesn’t stop with the residents. Last year, my hospital’s quality-management department actually gave report cards to physicians on the faculty, grading us on how well we were doing on core measures, like advising patients with heart disease to quit smoking. While that may sound like the most rudimentary possible yardstick, sometimes the simplest yet most effective protocols are the first to be forgotten in the middle of a busy day.

As anybody who’s ever had to wait six months to see a big-name specialist or gotten hopelessly lost in a basement on the way to get blood drawn can attest, big hospitals are by no means the only solution for your medical needs. For a relatively minor procedure, like gallbladder removal, it probably doesn’t matter which hospital you go to. A community hospital may provide care comparable to a large, urban facility, and you may even get more personal attention. It’s also true that some smaller hospitals have established niches of care—for orthopedic problems, say, or strokes—that compare favorably to big general-care hospitals.

Still, if I were in trouble, and I had a choice, I’d go to one of the big hospitals. I remember a patient I treated during my fellowship at NYU: a middle-aged man who had collapsed several days earlier on a subway platform with a heart attack. Paramedics arrived, and they did all the right things: They gave him an aspirin to chew, placed nitroglycerin under his tongue, and administered oxygen through a face mask. Then they took him to a nearby hospital that did not perform angioplasty. The procedure, in which tiny balloons and stents are used to open blocked coronary arteries, is the best treatment for a heart attack if done expeditiously by experienced doctors. Instead, the man received a clot-dissolving drug—a thrombolytic—which in his case, unfortunately, didn’t work.

By the time he was transferred to my hospital for angioplasty, it was too late. He was already exhibiting signs of heart failure. At this point, there was little reason for us to open his blocked coronary artery, because the part of his heart that is fed by the artery was permanently damaged. If he had been brought directly to NYU, which had a cardiac-catheterization lab open 24 hours a day, the damage to his heart could have been averted, adding years to his life. Do you need a better argument for big teaching hospitals?

Dr. Sandeep Jauhar is director of the Heart Failure Program at Long Island Jewish Medical Center and the author of the forthcoming memoir Interred, to be published by Farrar, Straus & Giroux.

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