Hospital quality and market share

The following originally appeared on The Upshot (copyright 2016, The New York Times Company). It also appeared on page A3 of the August 23, 2016 print edition of The Times.

There’s an exceedingly simple way to get better health care: Choose a better hospital. A recent study shows that many patients have already done so, driving up the market shares of higher-quality hospitals.

A great deal of the decrease in deaths from heart attacks over the past two decades can be attributed to specific medical technologies like stents and drugs that break open arterial blood clots. But a study by health economists at Harvard, M.I.T., Columbia and the University of Chicago showed that heart attack survival gains from patients selecting better hospitals were half as large as those from breakthrough technologies.

That’s a big improvement for nothing more than driving a bit farther to a higher-quality hospital.

Because more Medicare patients went to higher-quality hospitals for heart attacks between 1996 and 2008, overall chances of survival increased by one percentage point, according to the study. To receive care at a hospital with a one-percentage-point gain in survival rate or a one-percentage-point decrease in readmission rate, a heart attack patient traveled 1.8 or 1.1 miles farther, respectively.

The investigators also found survival gains for heart failure and pneumonia, but with far less of a difference, about 0.21 and 0.10 percentage points.

Although it’s clear that more patients have sought care at better hospitals over the years, exactly how they figure out which ones are better is less clear.

Identifying a better hospital on your own may be conceptually simple, but in practice it’s not so easy. (Obviously, this is something you’d want to consider in advance of an emergency like a heart attack.) There are several websites that convey various metrics of hospital quality.

For example, on Medicare’s Hospital Compare site, you can learn which hospitals have lower-than-average mortality rates for five medical conditions — including heart attacks, heart failure and pneumonia — and two surgical procedures. You can also find which have higher-than-average readmission rates for the same conditions and procedures, as well as over all.

And you can pore over statistics on 11 measures of patient satisfaction; on almost 50 ways to assess the timeliness of effective care; on nine kinds of complication rates; and on six ways to assess appropriate use of imaging, like M.R.I.s.

Your head may already be spinning. But if you wanted even more information, you could read about deficiencies compiled during hospital inspections at, run by the Association of Health Care Journalists. There are also state-specific websites, like New York’s or California’s.

Perhaps because of the complexity of sifting through all this information, most patients don’t choose hospitals this way. More likely, many rely on their doctors for recommendations. Doctors are more attuned to clinical quality than patients can be, because patients lack the expertise and don’t engage with the health care system frequently enough to evaluate hospital quality.

“Our results fit with the view that hospitals’ reputations spread through social networks of patients and doctors influencing the decision over where to seek care,” Adam Sacarny, an economist at Columbia and one of the study’s co-authors, said.

Rather than clinical quality, which is hard to perceive, patients may be more directly attuned to how satisfied they, or their friends and family, are with care. That’s something they can more immediately experience and is more readily shared.

Fortunately, most studies show that patient satisfaction and clinical measures of quality are aligned. For example, patient satisfaction is associated with lower rates of hospital readmissions, heart attack mortality and other heart attack outcomes, as well as better surgical quality.

Hospitals could also improve patient experience in ways that have nothing to do with quality of care: Nicer TVs in the rooms or more opulent lobbies don’t reduce mortality rates. For this reason, we should not assume that greater satisfaction necessarily means better medical outcomes. It’s still a good idea to check the quality ratings and consult with your doctor about where you’ll get the best care — and not be put off if it means driving a bit farther. It could save your life.


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