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What Is Quality Health Care?

By Arvind Suguness

During the third year of medical school students leave behind their textbooks and venture into the world of actual patient care. We get the chance to experience a range of specialties and to gain a provisional understanding of the intricacies of our health care system. During my third year, I have had the opportunity to see a wide variety of hospital settings, ranging from a wealthier private hospital, to a community hospital serving a disadvantaged patient population, to the resource constrained veteran’s affairs (VA) hospital system.

The differences between these environments could not be more dramatic. The wealthy hospital is a wonderful place to work. The rooms are beautifully furnished, the food in the cafeteria is delicious, and even the elevators have wood paneling. The VA, on the other hand, can be a depressing place, with furniture that often looks plucked straight from the 80s, cafeteria food that borders on inedible, and a distinct lack of wood paneling.

The differences are not limited to the superficial, either; they extend into things one would assume have a large impact on patient care. For example, the lab at the wealthy hospital works much faster, which can seem important when you are forced to wait 45 minutes on a lab result before closing a patient’s incision, as happened during my time at the VA. At the wealthy hospital, most everything runs 24 hours a day, seven days a week, but at the VA, numerous services such as imaging or stress tests can be unavailable outside of weekday working hours.

These disparities inevitably color how those working at the VA come to view it. Many of the residents and other medical students I worked with expressed a low opinion of the quality of care the VA provides and I too found myself thinking of it as a low quality institution. But are these perceptions true? Does our subjective experience of working at an institution necessarily line up with the reality of its results?

The answer, at least in the case of the VA, appears to be no. In his 2007 book Best Care Anywhere: Why VA Health Care Is Better Than Yours, Phillip Longman runs through some of the evidence demonstrating the VA’s high quality of care.

One 2006 study compared the life expectancy of elderly patients cared for in the VA system with those enrolled in Medicare Advantage and found 2 year mortality was 40 percent lower in males and 24 percent lower in females in the VA system. Another study compared rates of treatment for high blood pressure and found 77 percent of patients were successfully treated in the VA system, versus just 67 percent of those with commercial health care. Other studies have found lower rates of surgical complications, superior performance across a host of quality measures, and better customer satisfaction scores. All this is despite the fact VA patients are generally sicker than those in the commercial health care system.

The lesson, then, is that many of the factors students and physicians come to judge an institution by have little or nothing to do with the quality of that institution. Perhaps receiving lab results back within minutes is less important than creating an organized system of care. Perhaps being able to order any study at any time is less important than having an electronic medical record which actually contains all of a patient’s information.

As our health care system undergoes a transformation in the coming years, it will be important for us to understand the makeup of high quality health care. We will be confronted with innumerable quality measures and be forced to decide how we can best improve the well-being of our patients. It will be important to keep in mind the lesson of the VA: relying on our own experience can often lead us astray and solving the problems of our health care system will require us to challenge our preconceptions.

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