Aggressive hospital care might not be best care

When it comes to hospital health care, more isn't necessarily better, says Consumer Reports, which has published a free Web tool allowing patients to compare the intensity of care given at hospitals around the country.

More aggressive care can result in an increased risk of infection, medical errors and uncoordinated care, says the report, headlined: "Too much treatment? Aggressive medical care can lead to more pain, with no gain." Patients, the report says, should know how their hospital ranks.

In the Seattle area, hospitals treated patients much less aggressively than did hospitals in some other large cities, such as Los Angeles, New York and Miami. But the report still showed a large variation here, from hospital to hospital, in the care received.

The report, published on Thursday, relies on data from a 2008 Dartmouth Atlas of Health Care study of seriously ill Medicare patients at nearly 3,000 hospitals from 2001 through 2005, as well as earlier studies. Scores reflect days in the hospital and visits from specialists, while earlier research looked at surgeries, procedures and tests, as well as costs and patient satisfaction.

Dr. Elliott Fisher, principal investigator at the Dartmouth Atlas Project, said studies done by Dartmouth over the past eight years have consistently concluded that aggressive care does not improve outcomes for patients.

"Higher intensity care was associated with slightly worse quality and slightly worse patient satisfaction," Fisher said. "Hospitals are dangerous places if you don't need to be there."

Patients were all 65 or older, and were treated for the top nine leading causes of death, including congestive heart failure, chronic pulmonary disease, cancer, dementia, coronary artery disease, chronic kidney failure, peripheral vascular disease, diabetes with organ damage, and severe chronic liver disease. All died within the study's five-year period, and researchers looked at the care they got in the last two years of life.

In Los Angeles, 20 hospitals scored in the 97th percentile or above for aggressive care, and the "most conservative" hospital was in the 72nd percentile.

By contrast, Puget Sound-area hospitals varied from the 2nd percentile of aggressiveness to the 44th.

Still, that variation among hospitals ought to concern patients, says Dr. John Santa, director of the Consumer Reports Health Ratings Center, because while a specific patient might benefit from aggressive treatment, "on average, aggressive hospitals do not have better outcomes, and may be worse."

Scores aren't a "rating," says Santa, but a ranking. "We would not want to say that an aggressive hospital is a bad or good hospital, or a conservative hospital is a good or bad hospital at this point."

However, he noted, some hospitals with the best reputations don't necessarily do more.

Swedish at upper end

In the Seattle area, Swedish Medical Center's hospitals (which include First Hill, Cherry Hill and Ballard) ranked as the most aggressive — in the 44th to 40th percentiles.

Swedish's director of clinical effectiveness, Jennifer Harville, said patients with more complex diseases are more likely to end up at Swedish because they can have access there to a broad array of specialty services.

For example, patients with vascular disease often have diabetes, issues with their kidneys and compromised immune systems that make them more susceptible to infections when they're receiving services at a hospital, she said.

Cassie Sauer, spokeswoman for the Washington State Hospital Association, said outlying, smaller hospitals, which more often ranked on the "conservative" side, frequently refer outpatients with serious chronic conditions.

Overall, the report reflects "very good research," Sauer said.

"But I think there are understandable reasons why some hospitals would be higher on the list than others," she added. "Swedish is a place where a lot of people get sent for referral for very serious cancers, very invasive brain tumors, major heart disease ... so it's understandable that you would get more services if that's the disease you show up with instead of appendicitis."

The Dartmouth data were adjusted for degree of illness, among other things, "with very good risk adjustment," Fisher countered, so the numbers compared patients similar in sickness, age, sex and race at different hospitals.

And although academic medical centers often argued that they provided expensive, aggressive treatment because their patients had more complex illnesses, Dartmouth studies focusing on those hospitals found that similar patients did just as well or better at less aggressive hospitals, Fisher said. "On average, higher intensity hospitals showed no gains in survival."

What patients might ask

The ranking published Thursday is a "first step," Consumer Reports' Santa said, aimed at translating complex statistical models into consumer-friendly information to help mobilize patients to ask more questions.

Santa hopes the rankings will help patients realize that hospitals vary in degree of aggressiveness about recommending tests, surgeries, procedures or specialty care, and that they should take appropriate steps, including asking lots of questions.

"Patients should be aware whether they're in a conservative or an aggressive hospital, and they should have a lower threshold for asking their doctors questions if the style of care they want doesn't match where they are," Santa said. For example, if they realize they're in a more aggressive hospital, they should ask questions about how their care is being coordinated.

"We always want people to ask those questions," said Sauer, of the hospital association. "I think patients should always ask: 'Is this treatment truly necessary? What are my chances, and what is the pain trade-off?' "

Other questions, she said, might include: "Why are you giving me that drug? Is my care being coordinated? Are you sure this is the right thing to do? Are the potential outcomes worth the risk and the money? What am I going to feel like?"

Scores from New York and Los Angeles, she said, made her wonder, "Are people just spending their last months getting test after test and procedure after procedure that potentially have no effect on their outcomes or make their lives more miserable?"

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com