According to a new study by investigators at The University of Iowa and the Department of Veterans Affairs (VA) Iowa City Health Care System, specialty orthopaedic hospitals serve a healthier population of Medicare patients compared to general hospitals. Peter Cram, MD, assistant professor of internal medicine, UI Roy J. and Lucille A. Carver College of Medicine, and lead author of the study, tells more about the study:
Explain the difference between a “specialty orthopaedic hospital” and a “general hospital.”
There are about 5,000—actually I think about 6,000—hospitals in the United States and most of those are general hospitals. And by general hospital, I mean that they treat old patients, young patients, men, women, children, all diseases; they’re capable of treating just about everybody.
The number of general hospitals has been falling by about one percent per year for say 20 years, and maybe even before that. Alternatively, the number of specialty hospitals has been growing very rapidly, and this is something that’s come on since about 1995. Specialty hospitals tend to focus on a specific disease or group of patients, so traditionally you might think about children’s hospitals as a type of specialty hospital. But the newer generations of specialty hospitals that have been growing are focusing on really lucrative, highly reimbursed procedures: in particular, cardiac care and orthopaedic care.
So the orthopaedic hospitals tend to focus exclusively on patients with orthopaedic conditions, and the idea behind this really comes from the specialization that you see throughout the U.S. economy. If you look at farming or manufacturing, you would see that the ‘jack of all trades’ really doesn’t exist many places in America anymore. Well, why should hospitals be a jack of all trades? They should specialize too, and that’s really how this developed.
What do you mean when you say specialty orthopaedic hospitals serve a “healthier” population of Medicare patients?
One of the widespread concerns about specialty hospitals is that they’re engaging in ‘cherry picking’ or ‘cream skimming.’ What this means is that one of the allegations or charges that have been made against specialty hospitals has been that they admit only the healthiest patients. What I mean by that is that the specialty hospitals admit patients who have a single medical problem, so in the case of orthopaedics, it would be someone who might need a hip replacement. But if they need a hip replacement and they have a hip infection, the specialty hospital won’t admit them. If they need a hip replacement and they have high blood pressure and diabetes, the specialty hospital won’t take them. They only take the very simple patients.
Who was included in the study?
Our study looked at Medicare beneficiaries, which are basically Americans 65 years of age or older, who were getting hip or knee replacements between 1999 and 2003 in 38 specialty hospitals and 517 competing general hospitals.
How many years did the study run?
It ran from 1999 to 2003.
How many cases of total knee and total hip replacements were included in the study? What were the findings of the study? Any surprises?
There were 38 specialty hospitals and 517 general hospitals and there 52,000 patients who underwent hip replacement and 100,000 who underwent knee replacement in those hospitals.
The first finding—and this was not surprising—was that specialty hospitals admit less complex patients than general hospitals. And again, what we mean by this is, specialty hospitals admitted fewer patients with diabetes, fewer patients with kidney disease; they generally admitted less complex patients. The surprising part that we found was that specialty hospitals had significantly better outcomes than competing general hospitals. And what I mean by that is patients in specialty hospitals had lower rates of complications after their surgery, and that was surprising.
From your study, should we conclude all Medicare patients should have specialty orthopaedic hospitals perform surgery on their total knee and hip replacements?
Well, our study did suggest that specialty hospitals may have better outcomes, but picking a hospital is complex and I wouldn’t recommend that at all. When it comes to picking a hospital, many things need to be considered:
- Location of the hospital relative to where patients live
- Patients’ comfort with that hospital
- Where the patients’ doctors practice
What I would say is that when patients are considering where to have their surgery, they should take all of those factors into account. Specialty hospitals may be a reasonable option, but another reasonable option—and this has been demonstrated in multiple, multiple studies—is that major academic medical centers also tend to have very good outcomes, as well. And so either of those, I think, are good ways to make choices. But a lot of factors need to be considered.
What are the next steps to look at based on the outcome of this study?
There are many directions to go. One, we are currently investigating whether or not specialty hospitals are admitting or avoiding patients with less desirable insurance. There’s widespread concern that specialty hospitals do what sometimes is referred to as a ‘wallet biopsy’: if someone can pay, they get into a specialty hospital; if they can’t, then they are turned away. And that’s one of the things we’re actively investigating.
The other thing we’re interested in looking at is what makes specialty hospitals potentially good. If specialty hospitals are good, are there lessons that can be applied to other hospitals and other diseases? And that’s another direction that we’re looking at. |
