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Are the elite academic hospitals always a patient's best choice?

Dr. Donald M. Berwick Dr. Donald M. Berwick, leader of the Institute for Healthcare Improvement in Cambridge and a prominent advocate for better healthcare quality, believes that community hospitals have advantages over teaching hospitals for routine care. (Chris Granger/ Times-Picayune Staff Photographer)
By Marcella Bombardieri
Globe Staff / December 28, 2008
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Dr. Donald M. Berwick may be the most influential figure in a global movement to improve the quality of healthcare. His organization enlisted 4,000 American hospitals in a campaign to dramatically drive down medical mistakes that kill tens of thousands of people a year.

So, where would he go if he had pneumonia?

"Right now if I needed something simple, I would tend to choose a great community hospital over a great academic hospital," said Berwick, leader of the Institute for Healthcare Improvement in Cambridge. "There's a lot of reasons to suspect that for relatively routine things you need . . . you would be better off at a caring, smaller community hospital that's taking quality seriously than in a massive, complex teaching hospital that's taking quality seriously."

Berwick's beliefs about routine care rest on a mix of data and instinct. They infuriate many academic doctors proud of the extraordinary knowledge they apply to curing their patients and training the next generation of physicians.

"If I needed to have my, I'll say, toenails clipped, I wouldn't go to Mass. General. OK. Probably that's true," said Dr. David F. Torchiana, head of the Massachusetts General Physicians Organization, when told of Berwick's comments. "Where does the line diverge? When would he go to Mass. General?"

Yet Berwick's point of view is gaining currency among other prominent doctors and researchers, who believe that teaching hospitals can be too busy handling all manner of complex care to always get the basics right, or that community hospitals have worked harder to improve quality in recent years than their academic counterparts. Even the CEO of Partners HealthCare, parent company of Massachusetts General and Brigham and Women's hospitals, says he considers academic and community medicine equal in quality except for complex care.

"If I felt there was a difference, I wouldn't move a patient from the Brigham to the Faulkner or from the General to North Shore," said Partners' leader, Dr. James J. Mongan, referring to hospitals within his system.

If there is a such a relative equivalence in quality, it isn't well reflected in the Massachusetts healthcare market. More than half of discharges were from teaching hospitals last year, according to the state, and the vast majority of them were for care that is available far more cheaply in community hospitals.

Generations of conventional wisdom - and years of hefty advertising by teaching hospitals - have reinforced a belief among Bostonians that the best treatment for nearly any illness can be found at one of the city's monuments to medical greatness. It is our particular regional obsession; one study found that only a fifth of hospital stays in other states are in academic centers.

Berwick does believe that teaching hospitals are best for some illnesses. For a triple-vessel bypass or esophageal surgery, for example, he would choose a teaching hospital, where doctors are generally more experienced at performing rare operations.

But when it comes to routine medicine, he and other healthcare specialists said, teaching hospitals, despite their many areas of excellence, can have a downside. They are enormous places with layers of doctors and nurses juggling a lot of very sick patients. Miscommunications occasionally happen. Emergencies can distract from other priorities.

Still, there's no definitive answer to the debate. Studies are contradictory. Barometers of medical quality are fairly embryonic - and controversial.

But there are efforts on many fronts to devise more persuasive comparative measures. In one example, Sir Brian Jarman an emeritus professor at Imperial College in London, has developed a method to calculate the death rates of entire hospitals in a way that they can be compared, despite differences in how sick the patients they see are. Jarman found that in 2000, 39 elite academic hospitals in the United States had a lower death rate than all other hospitals in the nation. By 2006, however, the situation had reversed. Both kinds of hospitals had seen their mortality rates decline significantly, but the elite hospitals now had a higher death rate than the rest.

Jarman, who has worked with Berwick's group, believes the community hospitals have worked harder to improve. Many teaching hospitals, he said, "probably feel they don't need to do all this stuff, they're good enough as it is."

Avery Comarow, editor of the U.S. News & World Report ranking of "America's Best Hospitals," said teaching hospitals are best for patients who need complex care and have few alternatives. Others should feel safe looking more locally.

"If you are 45 years old and need a knee replacement . . . and you don't have other complications, why not stay close to home?" he said. "Ask the right questions about how many [procedures the surgeon and the hospital] have done, about their mortality rate. If the answers are good, why in the world would you go someplace else?"

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