Lessons from an Emergency Room Nightmare

By Harold Pollack, The American Prospect. Posted December 18, 2008.

Key enzyme levels were very high, indicating that heart cells had died and had released their hidden proteins. Yet the staff remained unsure that the test equipment was working. As the tests were rerun, the staff tried to administer a CT scan, but the intravenous dye infiltrated into Veronica's forearm, causing excruciating pain.

I remained convinced this was all an annoying set of benign, if painful, screw-ups.

I cannot say why I was not more forceful in getting Veronica out of there. Throughout, she seemed fine, talking normally, except that her chest, and then her arm, really hurt. My alarm steadily increased as the realization sank in that something could be genuinely amiss. An amazing four hours after arriving, we received the repeated enzyme tests. That's when the ambulance was called to transport Veronica to a real hospital. I gingerly asked the doctor about taking her to the big university hospital one hour away. He replied, quite reasonably, that there was no time. I raced home and drove the kids to a friend's house.

At the hospital, an emergency-room doctor stated without preliminaries: "Bottom line -- you've had a heart attack." The enzyme tests were definitive. Fortunately there was no other detectable damage. He explained that this was the kind of heart attack, more common than one would suppose, that can leave no obvious damage. A tiny piece of plaque becomes dislodged, initiating clotting. Such an attack can be essentially self-healing once it runs its course. I gave the gruff but comfortably authoritative cardiologist the business card of Veronica's internist and asked him to call.

Veronica needed cardiac catheterization. This is a delicate procedure. Cardiologists and their surgical teams differ substantially in skill and in post-operative mortality. For 25 years, health-services researchers have documented that it's good to have an operation in the right hospital by the right people. Many jurisdictions have begun to publish hospital-specific and surgeon-specific rankings of observed and expected mortality rates for these procedures.

As you might imagine, ranking is a complicated subject. Hospitals complain they are penalized because they serve high-risk, complex patients. Hospitals may also game things. There is suggestive evidence that cardiac report cards encourage physicians to provide less-aggressive treatment to minority patients and others who tend to have worse outcomes. Risk-adjustment methods developed to address these concerns have spurred needed changes. A striking number of surgeons in the highest mortality categories retired or moved away when New York implemented report-card systems. A 2006 Health Affairs paper by Ashish Jha and Arnold Epstein reports: "With the release of each report card, approximately one in five bottom-quartile surgeons relocated or ceased practicing within two years." New York's post-operative mortality rates sharply declined after ratings were published. Rankings were not the only reasons for improvement, but they helped.

Not surprisingly, high-volume facilities perform better. Surgeons get better with practice. Care teams get better at minimizing post-operative infections. Some hospitals become popular because they are good; others become good because they are popular. Which came first? If you're a patient, you don't care. There are ongoing debates over whether cardiac catheterization and other delicate services should be provided by a small number of high-volume regional centers. Probably they should, though this is hard to pull off in our decentralized and competitive system. The data also reveal surprising disparities, sometimes between adjoining hospitals or those we might otherwise consider peers.

New York state publishes risk-adjusted 30-day mortality rankings. Based on 2003–2005 data (released last February), where would you want your ambulance to go in the New York area? You might not guess that Bellevue Hospital and the Long Island Jewish Hospital performed markedly better than many more famous hospitals. You might not suspect that Montefiore-Einstein Heart Center ranked poorly in both mortality and post-operative complication.

I have presented this information to hundreds of students at Yale, the University of Michigan, and the University of Chicago. I could cite a wealth of data on many topics. Yet when Veronica got sick, my personal databank included nothing on the hospitals near my own home. You don't comparison shop alongside a loved one's hospital gurney.

As the bedside conversation proceeded, I wondered whether to sell our house. I wasn't thinking about the sub-prime mess. I just wanted to live near a great cardiac facility. A classic analysis by Mark McLellan, Barbara McNeil, and Joseph Newhouse showed that people who happen to live near these hospitals were more likely to survive cardiac emergencies. I wish I had taken that paper to heart.

The community hospital that treated Veronica is, by reputation, probably the best within 10 miles of us. The attending cardiologist is well respected and projected an infectious certainty about what was wrong, how to fix it, and who was in charge. I found his decisiveness reassuring. Still, I would rather have had this performed at a major academic medical center or at least done by someone I had vetted. I again rather awkwardly asked the emergency-room docs whether Veronica should be moved. I called a friend who is a good internist who said they seemed to be doing sensible things, and there was no time to screw around moving her. Given the situation, there was nothing else to do.

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Harold Pollack is an associate professor at the School of Social Service Administration, and faculty chair of the Center for Health Administration Studies at the University of Chicago.

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