Gotham Gazette

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Grading the City's Public Hospitals

New York City is a world of infinite decisions: Japanese or Vietnamese, a ball game or the opera and the subway or a cab.

Some decisions, though, involve more serious matters. Selecting a hospital is one. But now New Yorkers trying to decide whether to go to Coney Island Hospital or Kings County Hospital Center have a little more information to guide them.

Last month on its Web site, the city’s Health and Hospitals Corporation voluntarily released infection and mortality rates for each of its 11 public hospitals. It was the first hospital system in the state to do so, said the corporation's chief executive officer and president, Alan D. Aviles.

The data, which is accessible here, compares the corporation's facilities with regional and national averages and allows New Yorkers to analyze and compare hospital against hospital.

Hailed by health care advocates for casting light on a secretive industry, the release of this data has shifted attention to the perception of public hospitals and their ability to provide quality care in all five boroughs. Although the corporation's acute care facilities score above state and national averages, a familiar discrepancy emerges within its own network: Hospitals in lower income areas tend to do worse than those in higher income areas.

The Information Trend

Although most of the information the corporation has posted on its Web site is regurgitated from either the state or federal hospital reporting system (which are also available online here federally and here on the state level), the corporation added specific mortality data on each hospital and statistics on infections acquired in hospitals. Since the corporation took this step last month, another New York hospital–North Shore Long Island Jewish Health System – has already followed its lead.

New York State began releasing hospital mortality data on coronary bypass surgery in the late 1980s. Then, the public information movement stalled. Advocates attributed this to an increasingly powerful health care industry and a reluctance to disseminate seemingly private information.

" If we back up 20 to 30 years, health care was a very private transaction between a patient and a physician," said former state legislator James R. Tallon, now the president of United Hospital Fund of New York, a health care policy organization. "In a sense it's sort of a movement to say we are going to make it more publicly available. We live in a world where information moves much more freely."

In 2005, the state legislature approved more rigorous reporting standards, which would result in the release of hospital report cards and hospital-related infection rates in 2009. Those regulations are currently being rolled out.

The Health and Hospitals Corporation's voluntary release of its data puts it a step ahead of the state statute.

The Corporation's Score

Overall, the corporation's hospitals have average mortality rates that are better than state, regional and federal averages.

However, its average mortality rate following heart attacks is slightly worse than the statewide figure – the corporation had 15.8 patients die within 30 days of a heart attack from July 2005 to June 2006, while the statewide average is 15.6. For heart failure, based on the same 30-day measure in the same time period, the corporation scored better than the statewide average -- 10.6 compared to 11.

Data on the death rates from heart failure and heart attacks were provided by the federal Centers for Medicare and Medicaid Services, which take into account only Medicare patients. Those patients, said Aviles, comprise just 15 percent of the corporation’s patient base.

When comparing the corporation's 11 hospitals, a familiar outcome is apparent: Facilities in the outer boroughs and in more impoverished neighborhoods have higher mortality rates than those in Manhattan.

" Quite frankly, we're talking about the hospitals in the outer boroughs and the health of the communities is often poorer," said Aviles. "There are more patients with low incomes, that are uninsured," he added.

For hospital wide mortality rates, the lowest ranking facilities – Coney Island Hospital in Brooklyn at 3.14 percent, Kings County Hospital Center in Brooklyn at 1.72 percent and Elmhurst Hospital Center in Queens at 1.64 percent – are all located in the outer boroughs.

The hospital wide mortality rates are not risk adjusted, Aviles said, and so do not take into account the types of patients or trauma seen at each location. Because the Coney Island center sees a disproportionate number of elderly nursing home patients and Elmhurst sees terminally ill patients needing hospice care, the figures might not accurately reflect the facility's quality. The hospitals with the lowest mortality rates, including North Central Bronx Hospital at .67 percent, followed by Manhattan-based Metropolitan Hospital Center at .68 and Queens Hospital Center at .96 percent, were not all in Manhattan either.

The corporation's acute care facilities are dispersed throughout the boroughs: Brooklyn has four hospitals, Manhattan has three and both the Bronx and Queens have two (Staten Island has one rehabilitation facility).

None of the three Manhattan facilities ever fell within the bottom quarter of the corporation's mortality lists, and one, Metropolitan Hospital Center, was always among the three hospitals with the lowest mortality rates based on hospital wide, heart failure and heart attack data. On the other hand, Jacobi Medical Center in the Bronx has one of the highest mortality rates for both heart attacks and heart failure.

Data on hospital-related infections had similar results. Patients in hospitals in the outer boroughs accumulated infections more frequently than those in Manhattan.

When comparing preventable, sometimes-fatal bloodstream infections affecting patients in intensive care units – otherwise known as central line infections – Kings County again sank to the bottom of the corporation's list with 11 per 1,000 CL days, which takes into account the number of days and amount of patients with a central line. A Manhattan hospital, Bellevue Hospital Center, topped the list with a rate of 1.7. Numerous hospitals in the outer boroughs went more than four months without having a central line infection.

The Health Care Gap

Because patients outside of Manhattan are more likely to be uninsured, said Aviles, they do not have the same access to preventative medicine. They may not have a primary physician or are recent immigrants. Also, the corporation's president added, many of the hospitals in the outer boroughs, like Jacobi Medical Center, Kings County and Elmhurst, serve as trauma centers – locations that would obviously see an influx of patients who are injured more severely.

The discrepancies in access to health care based on race and income have been documented previously. A report released last month by City Comptroller William Thompson showed residents of lower income neighborhoods are more likely to suffer from heart disease, diabetes and cancer than people in more affluent areas.

Although quality of care disparities by borough are evident in the corporation's data, many advocates said the public hospitals in poorer neighborhoods have come a long way since the 1990s.

Public Versus Private Care

The Giuliani administration’s lack of support for the city's public hospitals left the facilities without sufficient resources to provide proper care, said some advocates. And with that, they added, came the public perception that public hospitals were less reliable and safe than private ones.

The Health and Hospitals Corporation, however, has received renewed attention during Mayor Michael Bloomberg's tenure. With a $200 million boost to its operating budget in 2004, Bloomberg aimed at reinvigorating the public health industry. That effort has been seen in the hospital's greater ability to provide quality health care, said Aviles.

" We have a mayor that is very knowledgeable about health care," the corporation's president said. "We're just glad that we're getting to the point that we have data (that reflects) what the mayor is saying."

Even Aviles recognizes that many New Yorkers see public hospitals as riskier than private ones. That stereotype, he added, is outdated, thanks to Bloomberg.

The data helps point to the better quality of care at the corporation's facilities. Many of the intensive care units within the corporation have reduced central line bloodstream infections by 30 percent over the last two years, according to the corporation.

" There has sort of been over the years a public perception that public hospitals are not as good as private hospitals," said Arthur A. Levin, the director of the New York City based Center for Medical Consumers. "I'm sure that is the reason why HHC published this data. It makes them look really good."

The Data Debate

Because a large chunk of the data released by the corporation only measures Medicare patients and the overall mortality rates do not take into account a patient’s age or ailment, some advocates argue the data does not accurately measure quality of care.

Bruce Boissonnault, president and chief executive officer of Niagara Health Quality Coalition, which independently measures all the state's hospitals, said the corporation's move to release data is commendable, but medical consumers in New York State must keep in mind the source of information. Measuring whether a patient receives an aspirin when having a heart attack, does not necessarily mean that patient survives, he added. Context is everything.

"What you want to know is which hospital do I need to go to to walk out of the hospital alive, and where do I go to get a doctor that will follow up," said Boissonnault.

Boisssonault's group examines millions of anonymous patient records to score hospitals statewide. According to its measurements, most of the corporation's hospitals fall within the state average for mortality indicators based on inpatient conditions.

Since the state, let alone the country, are relatively new at collecting quality of care data, advocates said, no research methodology or data collection system is going to perfectly reflect a hospital's quality. "Because we're in the infancy of collecting data on (quality of care) measurements and reporting it, there are problems," said Levin. But, he added, "Do you wait for the perfect, or do you wait for the good enough?" 

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