1. Advocate Health Care, Oak Brook, IL
2. Cape Cod Healthcare, Hyannis, MA
3. CareGroup Healthcare System, Boston
4. Kettering Health Network, Dayton, OH
5. Maury Regional Healthcare System, Columbia, TN
6. Mayo Foundation, Rochester, MN
7. NorthShore University HealthSystem, Evanston, IL
8. OhioHealth, Columbus, OH
9. Partners Healthcare, Boston
10. Spectrum Health, Grand Rapids, MI

Thompson Reuters rated the hospitals on eight key criteria:

• In-hospital mortality
• Medical complications
• Patient safety
• Average length of stay
• 30-day mortality rate (post-discharge)
• 30-day readmission rate (post discharge)
• Adherence to clinical standards of care (evidence-based core measures published by the Centers for Medicare and Medicaid Services
• Hospital Consumer Assessment of Healthcare Providers and Systems patient survey score (part of a national initiative sponsored by the U.S. Department of Health and Human Services to measure the quality of care in hospitals)

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That’s according to a new survey done by the Sun Sentinel. The newspaper polled 105 southern Florida obstetrics/gynecology practices and found that 15 said they refuse to see patients who don’t meet certain weight cut-offs. The criteria most used was either a weight of 200 pounds or being classified as obese.

It’s not unheard of for overweight pregnant women to be referred to specialists, but more doctors are now refusing to see any overweight women — whether or not they are pregnant or planning to conceive.

The reasons given centered on two main points: Some practices said their exam tables and other equipment couldn’t safely accommodate larger patients. Others said they were afraid of increased liability since obese patients are more likely to have complications.

It’s legal for doctors to refuse a patient for any reason — even simple personality conflicts — as long as the reason isn’t discriminatory. But the AMA, among other critics, says the practice of refusing to see obese patients goes against the “spirit” of the medical profession.

Ethics aside, as the population in general gets heavier and less fit, excluding obese patients could make it harder for practices to stay in business.

What’s your take: Should doctors be able to refuse obese patients? Would you go to one who does? Sound off in the comments.

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A study in the Archives of Surgery compared age-matched patients undergoing the same surgical procedure. Those who had DNRs in place were three times more likely to die in the month following the procedure. The study accounted for the fact that the DNR group was sicker overall, and the difference in mortality rates remained. DNR patients also had more post-surgical complications.

Notably, the study found that the higher risk only occurred after some types of surgeries. For example, exploratory laparotomies had the highest risk for DNR patients, while thighbone fracture repair or appendectomies showed no difference in mortality rates.

The study authors say the results may help doctors advise patients with DNRs on which procedures would be more or less beneficial for them.

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In this case, the “best” hospitals are determined by choosing those hospitals that have mortality and complication rates in the top 5% for the most consecutive years. (To even the playing field, both rates are risk-adjusted based on the levels of severity of patient illness.)

Overall, patients being treated at one of the hospitals that made the grade had a nearly 30% lower risk of death and 3% lower rate of complications. According to HealthGrades, if all U.S. hospitals performed at this level, more than a half million deaths could have been prevented between 1999 and 2009 — just among Medicare patients.

Interestingly of the hospitals on the 50 Best list, 86% are not-for-profit or local government entities.

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Researchers looked at more than 84,000 surgical patients at 186 hospitals between 2005 and 2007. The death rate from complications ranged from 3.5% to 6.9% — even though the complication rate was roughly equal at all facilities.

The researchers found that management of common post-op complications such as surgical site infection, heart attack and post-op bleeds was a key factor in ultimate patient outcome — just as important as reducing the number of complications.

Relatively small steps such as quickly administering antibiotics for infections and making quick transfers to ICU when complications are noticed, as well as improving access to  cardiologists, made a significant positive impact on mortality rates.

The data came from the American College of Surgeons’ National Surgical Quality Improvement Program. The study was published in the New England Journal of Medicine.

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Reported events Jan.1 through Sept. 30, 2009:

• Wrong-site surgery — 126
• Unintended retention of foreign body — 97
• Delay in treatment — 94
• Operative/Post-op complications — 79
• Suicide — 72
• Patient fall — 65
• Medication error — 34
• Assault, rape or homicide — 27
• Perinatal death or loss of function — 26
• Patient death or injury in restraints — 9

Since JCAHO started tracking sentinel events in ’95, more than 6,500 patients have been affected, with 68% of the events resulting in death.

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Sound crazy? It’s not.

Especially for seniors or patients managing a chronic disease, the more relaxed one-on-one interaction of  a house call allows better patient care in general — specifically preventative care. The service is particularly useful in treating the home-bound, or those with mobility issues who often hesitate to make the trek to the doctor’s office as often as they should.

In the limited areas where house calls are being tried again, clinicians say they’re seeing fewer avoidable hospital admissions. In turn, fewer hospitalizations means less money spent and greatly reduced risk of complications.

While the upfront costs of this type of patient care is higher than a traditional doctor visit, in the long run it does save money. Various studies of pilot house call programs have found that it cuts the patients’ number of days hospitalized by one-half to two-thirds.

Would your physicians and nurse practitioners be willing to make house calls? Think it’d save money in the long run? Let us hear your thoughts in the comments.

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