From the publishers of the New England Journal of Medicine

When my physician father had problems with his throat a number of years ago, we quickly realized that his local Midwestern hospital couldn't offer him the specialized treatment he needed. With a few phone calls, we arranged for him to go to the Mayo Clinic, where he received excellent care.

Our "connections" certainly helped. But even without them, you too can pick a hospital where you or a family member will receive excellent care for an operation, tests, treatment, or a second opinion. It takes some common sense, the time to do a bit of investigating, and the persistence (or chutzpah) to ask some difficult questions. Published resources such as "hospital report cards" or US News and World Report's annual list of America's top hospitals can be helpful guides, as long as you keep their limitations in mind.

Searching for Quality

Perhaps the simplest, most effective thing you can do is pick a skilled, caring physician whom you trust. Then if you ever need to be hospitalized, you will get your care where he or she has admitting privileges. You are far better off in the hands of your chosen physician at a second-tier hospital than you are in the hands of a less-skilled or less-caring physician at a first-tier hospital.

Some people, however, prefer to work in reverse. You might want to choose a physician on the basis of his or her hospital admitting privileges, or if you join a health maintenance organization (HMO) because of the hospital it is affiliated with. Here's where the investigating begins:

Decide whether you prefer a community hospital or a teaching hospital affiliated with a medical school.

Community hospitals don't always staff a full range of medical services 24 hours a day. However, a smaller hospital may be friendlier and provide more personal care, may be less expensive, and may be more convenient.

Teaching hospitals generally have a full range of medical specialists available on a moment's notice. Some people believe that teaching hospitals offer better care because multiple layers of health care professionals oversee the care of each patient, and because physicians who teach and do research are more likely to be familiar with the latest techniques. The tradeoff is that your care may involve medical students and physicians-in-training.

Report Cards

You may have heard about hospital report cards. The term conjures up images of those official documents you once carried home from school. Unfortunately, they aren't nearly that specific. They focus mainly on measures we think are linked to quality, such as the number of board-certified physicians on staff or the ratio of nurses to patients.

More useful would be reports of death rates for specific procedures, or complication rates, or how quickly patients return to work. That way you could rate how one hospital compares with another in what really counts. But such evaluations are in their infancy, and the few that exist are hard to interpret. Take the case of two 66-year-old men who enter different hospitals for coronary bypass surgery. One smokes, has diabetes and high blood pressure; the other exercises regularly and is in otherwise excellent health. You can't accurately compare the hospitals on the basis of these two patients' surgical outcomes.

Paradoxically, a hospital with a high death rate for people getting bypass surgery just might be an excellent place to have such an operation. That's because a highly experienced staff may attract the toughest cases and operate on people that other hospitals wouldn't touch.

Despite these complexities, the practice of evaluating hospitals continues to spread, and has inevitably spawned a host of hospital rankings. Perhaps the most familiar is US News and World Report's best hospital list. It includes only teaching or medical school-affiliated hospitals, or those that score high on a "technology index," and ranks them using a formula that is equal parts reputation, death rates, and objective indicators. If you are looking for a top-notch hospital, the list is a good place to start. The magazine's formula still has a long way to go—as discussed earlier, mortality and complication rates can be misleading. And keep in mind that a good reputation can linger long after the quality has changed for the worse.

The Health Care Choices series published by Families USA (800-699-6960) lists the hospitals and health plans in several major cities, along with physician information and helpful "points to consider." This takes some of the legwork out of comparing hospitals, leaving you to do the more subjective investigation.

Reliable hospital report cards probably won't be available until the turn of the century. Until then, the advice of a trusted health care professional and some research of your own can help you select the hospital that's right for you.

Harry L. Greene II, MD

                                                                                           
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