If you suffer from a serious chronic illness, or you need major but elective surgery: Are you better served by the familiar hospital right down the road or the prominent medical center 90 miles away? See what experts in lung disease, heart conditions, cancer and orthopedics say about when your local hospital is a perfectly good option for routine procedures and when to seek the next level of care from an academic medical center, a major hospital system or a specialty center.
Total hip replacements and knee replacements are among the most commonly performed surgeries in the U.S. and can very well be done in a community hospital versus a world-renowned orthopedics facility, says Dr. Alexandra Page, an orthopedic surgeon in a private practice in San Diego. Access is a big part of the equation, Page says – a highly acclaimed hospital center is no help to a patient if it’s unattainable due to distance or insurance coverage issues.
When considering high-tech treatments only available at certain centers instead of standard therapy, Page says, you should avoid being the first patient to undergo a procedure – but never be the last one to have it, either. Be ready to move on when a practice is outdated, she advises. However, she adds, “Some of the other things that sound sexy and appealing, trying to generate buzz, often don’t make a difference.” With robotic joint replacement, for instance, she says the research literature is “borderline at best.”
But there are times when specialty centers make sense. With musculoskeletal tumors, like breast cancer that’s spread to the bones, it’s important a specialist handles it, Page says. Similarly, community hospitals may not have the resources for complicated joint surgeries such as complex revisions for deep infections or worn-out implants. Orthopedic surgeons know when to refer patients onward, if their facility doesn’t perform a procedure often enough or specialized equipment isn’t available.
“In commonly occurring diseases, and commonly occurring problems, we’ve got pretty good data to show that a community hospital and community doctor can do a very good job handling those things,” says Dr. Otis Brawley, chief medical officer for the American Cancer Society. “And indeed, sometimes, can do a better job than a tertiarycare facility.”
For example, Brawley says, a woman with early-stage breast cancer receiving standard chemotherapies Adriamycin and Cytoxan might do better locally. “If you go to a large university hospital or cancer center that employs 80 chemotherapy nurses – they give it, but they may not give it as often,” Brawley says. Instead, those nurses are giving a wide variety of chemotherapies to many more patients.
Clinical studies are a sign that a hospital is keeping up with the latest cancer research. “Many of your local hospitals actually participate in National Cancer Institute clinical trials,” Brawley says. Community hospitals offer convenience – patients often get through X-rays and other tests faster and spend less time waiting to see physicians, says Brawley, who practices at the Emory Winship Cancer Institute, a major referral center in Atlanta.
Higher-tier hospitals become more important as care becomes more complex, Brawley says. With lung cancer requiring chest surgery, for instance, consider a referral facility. Also, “Tertiary care centers tend to be much better in taking care of the out-of-the ordinary, unusual cancers,” he says. With certain complex spinal tumors, a major cancer center is indicated.
Brawley says proton beam radiation – an expensive therapy delivered at a handful of U.S. centers – is only backed by evidence as a better choice in cases of pediatric brain tumors, and for adults, with tumors in the sellar region of the brain, because it avoids damage to nearby neurological structures.
For patients with lung conditions like chronic obstructive pulmonary disease, it’s important to find a local pulmonologist as well as a primary care doctor, says Dr. Albert Rizzo, senior medical advisor for the American Lung Association. These providers can determine whether the community hospital can meet COPD patients’ needs, and when to refer patients to specialty centers, says Rizzo, who is chief of pulmonary and critical care medicine at Christiana Care Health System, based in Wilmington, Delaware.
Community hospitals can have excellent medical teams, Rizzo emphasizes, with physicians encompassing wide-ranging backgrounds, including experience in academic centers and research. However, he says, there should be a discussion of what comes next when asthma or COPD patients have been through a stepwise ap
proach to medical treatment, but suffer from worsening or unstable disease with flare-ups.
With referrals to specialty centers, patients may seek another opinion to make sure their treatment is appropriate and their diagnosis is accurate, Rizzo says. An academic center could be the best bet for clinical trials offering access to new medications. Certain lung procedures – such as surgical or nonsurgical volume-reduction techniques for patients with COPD – would be done at a referral center rather than a community hospital.
When people move to a new area, they should take an advance look into local health care options, says Dr. Andrew Freeman, who serves on the patient-centered care committee of the American College of Cardiology. If you have a chronic condition like heart failure, where would you go? What’s a good place for common heart procedures?
“The vast majority of stents and bypass surgeries are done on a more elective or at least semi-elective basis – it makes sense to do a little bit of research and homework,” Freeman says. That includes going out to meet the surgeon, asking for a reference or two and reading online.
For programs like cardiac rehabilitation, a suburban hospital may be as good as better-known heart centers. “The community hospital gets a bad rap, but in many situations, the community hospital has nicer overall physical facilities than the older academic hospital,” says Freeman, director of clinical cardiology at National Jewish Health in Denver. “I always tell people that community hospitals may have some of the most talented people, the best outcomes – even better sometimes than academic hospitals.”
On the other hand, Freeman says, “If you have a complex condition that’s not sort of standard, going to a specialized center, what we call either a tertiary or quaternary referral center – usually academic hospitals – makes sense.” Those centers may excel in very precise areas, he says. The Philadelphia area where he trained was packed with academic teaching centers: “Some were fantastic for a heart transplant, and some were fantastic for TAVR [transcatheter aortic valve replacement], and some were fantastic for bypass surgery.”
Procedures like heart transplant obviously fall into the specialty-center category. Even so, Freeman says, “An enormous amount of evidence suggests that people who are undergoing heart transplant or valve transplant or bypass surgery – when they’re near family and support and caregivers, they do better.”
“People identify a hospital with their community,” says Dr. John Combes, senior vice president and chief medical officer for the American Hospital Association. “In some small cities and certainly more rural areas, it may be the only hospital within 25 miles or so. In major metropolitan areas, sometimes the academic medical center is your community hospital.” What’s most important, he says, is for patients to go where their best support systems – family and community – are available. So traveling for a major procedure might not be best.
For objective criteria on overall performance and specific procedures, Combes advises patients to check outcomes not only on Medicare’s Hospital Compare but also Physician Compare. It might be better to turn to a major medical center, teaching hospital or specialty center if you have a very rare or obscure diagnosis, he says. Or consider a center of excellence around your particular illness if you’re seeking breakthrough treatments and related technology. Another option is to search for magnet hospitals, recognized by the American Nurses Credentialing Center for nursing excellence and outstanding patient care.