I was teaching the Virginia Mason VMMC case in Tech & Operations Management yesterday, and made a loose comment about busy urban hospitals being better than suburban ones. For example in the UC San Diego system, when someone is my family is really sick I try to take them to the downtown (dilapidated, overcrowded) UCSD hospital before I’d go to the one near campus (hotel-like, luxurious).
A student asked “why”, forcing me to do a little research. Here is my answer to her.
P asks: why are urban hospitals better? My answer: It’s a good question at 2 levels.
1) Is it true? How do we know?
2) If it’s true, why is it true?
The answer to Q1 is “yes, on average.” But we now have data on individual hospital quality of care for various metrics, so I recommend consulting that for personal use. More precisely, on average the following characteristics seem to be associated with quality of results in hospitals:
- Teaching hospital (affiliated with a medical school and teaching its students)
- Large hospital
- Busy hospital
All 3 of these are associated with “urban” versus rural. (see note at bottom). However, if patient satisfaction is the measure, some of these relationships reverse! Large busy and impersonal hospitals may be good for health, but not for comfort!
WHY? I don’t know of much research on this. But my understanding is that 1) it’s important that doctors and staff have seen lots of similar cases to your illness. This is more likely in large/busy hospitals. 2) Teaching hospitals and other so called “third level” hospitals get all the really difficult, obscure diseases, and more seriously ill patients. They therefore get more experience with them. After that we can speculate. For example does having to explain your actions to lots of 20-something students keep the age 50+ faculty doctors on their toes, trying to outsmart the students? (See the TV show: House, and probably others.)
Further speculation: uptake of new disease-management concepts such as safety protocols and Electronic Health Records is bigger in large systems. To the extent these are useful for patients, it will also improve large hospitals versus small ones.
For blog readers, if you have other or better information on this, please make a comment. Thanks!
NOTE: I did a scholar.google.com search on: urban hospital “quality of care” teaching large small ; for last 5 years, and found a variety of articles.
Main outcome measures: Differences between urban acute care hospitals and rural critical access hospitals on quality care indicators related to acute myocardial infarction, heart failure and pneumonia.
Results: For 8 of the 12 hospital quality indicators the differences between urban acute care and rural critical access hospitals were statistically significant (P = 0.01). In seven instances these differences favored urban hospitals. One indicator related to pneumonia favored rural hospitals (2007 article)
Art and Science in Technology - Roger Bohn's Blog 
I definitely find the associated characteristics on hospital quality interesting, as they probably match patients’ perceptions on the quality of the hospital as well. Being a busy hospital signals to the patient that they have plenty of experience to deal with their issues, and a large hospital may suggest that they either 1) were successful enough to expand, or 2) have enough resources to care for the patient’s needs. (I’m ignoring the patient comfort issue, although a short side story I’ll share–one of my teachers was trying to teach her physicians to warm their hands before touching the patient, because hospitals are cold and the blankets are thin, and the last thing the patient needs are cold hands touching them.) Large hospitals may also benefit from a “network effect” of sorts, housing all sorts of specialties to make them a one-stop shop for patients with complex issues. Patients from all over the world go to Houston for all types of specialty care due to perceived quality (and possibly experimental treatments).
I asked “why?” because a family member experienced severe unknown chest pains while we were hiking in the middle of nowhere, and though we went to one hospital and everything seemed to check out fine, all of the adults with us decided that we were going back to Houston “because [we] think Houston is better.” I privately disagreed, thinking that as long as local hospitals met the same standard, the results should be the same; but the data may support patient perceptions after all.
Teaching hospitals are a curious case though. They advertise the doctors that know their stuff because they teach the same subject over and over again through the years, and have most likely written textbooks as well–if they don’t know how to treat a condition, no one will. Therefore the quality of care should be the best of the best. But as a former dental school patient, I was mostly handled by students, not the actual teaching dentist; does this apply to teaching hospitals as well? Somehow the quality of care at teaching hospitals, then, also involves credibility; it involves convincing patients like me that the level of care I was getting from the students was somehow the same level I would get if I were only with the teaching dentist, or that I would receive both the experience of the teaching dentist and the energy/deftness of the younger students. Regardless of my hypotheses, I think no one will deny that the quality of care I received relative to the price of the treatment was certainly top notch.