Slender and in his 60s, the patient had been short of breath for several days, a result of untreated heart failure causing fluid to build up in his lungs. Despite his wife's entreaties, he had refused to go to the hospital, one of the biggest in the city, and waited at home, gasping, until his appointment at our clinic.
When I asked him why, he looked disgusted. "Have you ever been in that hospital?" he snorted, rolling his eyes. The halls were dingy, he continued; security guards were everywhere, accompanied occasionally by a shackled patient from the local prison; and the waiting rooms were veritable dens of human misery, filled with patients and their families stuck in endless holding patterns.
"Who knows what kind of care I would have gotten in one of those hospitals," he said with a shudder.
My patient was describing a so-called safety-net hospital, a place known for taking in those who have no insurance and cannot afford to pay for their medical care. Safety-net hospitals have long been considered the ugly stepchild of the American health care system. A heterogeneous mix of religious or public hospitals and academic teaching institutions, these medical centers have traditionally faced tremendous budgetary constraints that have forced many to forgo renovations and even routine maintenance to keep their doors open.
The assumption for many patients and doctors has been that the quality of patient care, like the ambience, suffered as a result. And while several early studies comparing patients' outcomesconfirmed those suspicions, a recent study published in the journal Health Affairs validates what those who have actually worked in safety-net hospitals have long believed: Just as you can't judge a book by its cover, you can't assess the quality of a hospital's care by its decor.
Researchers analyzed the outcomes and readmission rates of patients who were admitted to safety-net hospitals in almost 150 cities with one of three common -- and potentially devastating -- diagnoses and compared them with similar patients who were cared for at hospitals with significantly fewer uninsured or disadvantaged patients. They found that for patients with pneumonia, heart failure or a heart attack, there were negligible differences in the quality of care received, with some safety-net hospitals actually achieving better results.
The findings reflect the increasing sophistication over the last decade of research on hospital quality of care. Earlier studies tended to compare patient outcomes in sweeping strokes, lumping the experiences of medical centers situated in densely populated urban centers with those in suburban or rural settings. In this study, however, researchers confined their comparisons to cities. "We were comparing hospitals right across the street from each other," said Dr. Joseph Ross, lead author and an assistant professor of medicine at Yale University's School of Medicine. "It was more of an apples-to-apples comparison."
While it is reassuring to know that safety-net hospitals are capable of delivering excellent care, the study also raises questions. It's not known, for example, why certain institutions, including some of the safety-net medical centers that are more financially constrained, managed to excel while others struggled. It's also unknown how long these results will remain valid, since the Supreme Court ruling on Medicaid expansion in the Affordable Care Act may result in safety-net institutions getting even less compensation than they do now.
But just as the ability to conduct research on hospital quality improves, so will the amount of information available to the public. Seven years ago, Medicare began requiring hospitals to submit information on how they were doing in caring for patients with pneumonia, heart attacks and heart failure, and then publicly report that data on a Web site aptly called Hospital Compare. Since 2005, Medicare has added more measures, among them mortality and readmission rates for certain diagnoses, success rates in preventing certain infections and even some patient satisfaction measures.
Still, how hospitals do with most diagnoses and treatments remains unknown. "We've made a lot of progress," said Dr. Elizabeth E. Drye, one of the study authors and director of quality measurement programs at the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital. "But we still have a long way to go."
The researchers are continuing to work on developing more ways to use patient outcomes to assess and compare hospital quality. "Patients need to have the information that helps them make informed decisions," Dr. Ross said. "They shouldn't have to make assumptions based on what a doctor down the street says or what the building might look like."
He added, "They need to be able to know if it is providing high-quality care and matching the other institution down the block."
