“They messed my life up,” Ms. Yacketta said of her surgeons. “I hope those doctors rot.”

Dr. Lai, who has left University and now practices outside Chicago, acknowledged that he and his surgical team had accidentally injured Ms. Yacketta but said he had not been negligent.

Mistakes happen even at good hospitals, of course. But evidence shows that University, which is owned by the State University of New York system, is not a good hospital. In fact, in late 2006 a state commission recommended that it be scaled back and merged with another hospital.

The state’s inability to follow through on that plan for University provides a stark example of how hard it can be — not just in New York, but around the nation — to close or shrink hospitals, even when there is evidence they are providing costly and below-average care.

Certainly the evidence against University Hospital was strong. In 2006, patients at University were three times as likely to develop infections stemming from hospitals as were patients at the average New York hospital. HealthGrades, a company that rates hospitals using data from Medicare, ranks University among the least safe hospitals in the United States — although the hospital’s executives strongly dispute that assertion. University, meanwhile, is expensive to run.

Yet, today, University remains under state ownership. And far from shrinking, University is expanding.

Unlike some other nations, including France, the United States has no federal agency charged with hospital oversight. Instead, it relies on a patchwork of state health departments and a nonprofit group called the Joint Commission that sets basic quality standards for the nation. Hospitals are rarely closed or hit with significant financial penalties for hurting patients.

One of the reasons is that even troubled hospitals are major employers, and communities generally rally behind them when they face the threat of cuts, as Syracuse did for University.

“We haven’t been forthright about the dirty little secret, the huge variation of quality and safety in the system,” said Arthur Aaron Levin, director of the Center for Medical Consumers, a nonprofit patient advocacy group. Nearly a decade after the Institute of Medicine report, preventable errors remain shockingly common, said Mr. Levin, who was a member of the commission that wrote the report.

“It’s nine years later, and we can’t even tell you if it’s better,” Mr. Levin said. “How is that permissible?”

Any effort to maintain national standards is left largely to Medicare and the Joint Commission, a nonprofit group based in Oakbrook Terrace, Ill., which along with state health departments certifies that hospitals are operating safely.

But the commission lacks the heft and enforcement powers of a federal regulator. With fewer than 1,000 employees, it accredits and sets patient safety goals for 17,000 hospitals, nursing homes and assisted-living providers nationally. A typical survey lasts less than a week and involves fewer than a half-dozen examiners, said Dr. Mark R. Chassin, the president of the Joint Commission.

Hospitals account for the largest single slice of the nation’s medical spending, 31 percent, or about $650 billion in 2007, according to Medicare. Despite that enormous bill, hospital care is uneven, and often deadly. In 1999, a report from the Institute of Medicine found that hospital errors caused as many as 98,000 deaths a year in the United States.

Medicare is pressing for quality improvements, using as leverage the $155 billion it spends on hospital care annually. But Herb Kuhn, deputy administrator of the Centers for Medicare and Medicaid Services, said hospitals would not make patient safety their top priority until Medicare changed its reimbursement system.

At present, Medicare pays the same amount to a hospital for treating a patient, whether that patient lives or dies — even if the hospital made a preventable error that caused the patient’s death. On Oct. 1, Medicare began a project to end payments for a handful of “hospital-acquired conditions,” Medicare-speak for illnesses caused by preventable errors. But the program is scheduled to reduce reimbursement by only $21 million in 2009, not enough to make a major difference, Mr. Kuhn said.

“We’ve got to get our payment systems changed,” he said.

States’ Efforts

While Medicare experiments, states are making their own halting efforts to improve quality while lowering costs. Among the first was New York, which in April 2005 created an 18-member panel to make systematic recommendations about which hospitals and nursing homes should be closed statewide.

The need for change is acute in New York, which has among the most dysfunctional and expensive health-care systems in the nation. In 2004, New Yorkers and their insurers spent an average of $6,535 for each patient on health care, 24 percent more than the national average. Yet New Yorkers are more likely to die from chronic disease than people in any other state.

The legislation that created the panel, generally called the Berger Commission, after its chairman, Stephen Berger, provided that its recommendations would become law unless lawmakers overruled them.

But the legislation also provided that the state Health Department, not the commission itself, would enforce the commission’s recommendations. That loophole would eventually prove crucial.

On Nov. 30, 2006, after studying the state’s health-care system for almost two years, the commission announced that nine hospitals should close and 50 others should shrink or merge. Among the commission’s recommendations was that University Hospital be joined with Crouse Hospital, its neighbor in Syracuse, and that the new hospital have fewer than 600 beds, compared with the 366 beds at University and 576 beds at Crouse, a private nonprofit hospital.

Both hospitals had problems. In 2006, patients at University had a 1-in-37 chance of suffering postoperative blood infections, compared with a 1-in-65 chance statewide, according to the Niagara Health Quality Consortium, a nonprofit group that analyzes hospital billing records.

They had an 8.6 percent chance of dying from pneumonia, compared with a 5.5 percent chance statewide. Like HealthGrades, Niagara tries to adjust the data so that hospitals are not penalized if the patients they treat are sicker to begin with than those that the average hospital treats.

Crouse, for its part, had filed for bankruptcy protection in 2001 and was running at 50 percent occupancy. Of all the commission’s recommendations, merging University and Crouse “was the most obvious,” Mr. Berger, an investment banker, said in a recent interview.

But University and Crouse disagreed. Days after the commission released its report, Dr. David R. Smith, the president of Upstate Medical University, the state-run medical school that owns University Hospital, began lobbying Eliot Spitzer, then the governor, and Dr. Richard Daines, the state health commissioner, to undo the recommendation.

“We’re a university, not just a hospital,” said Dr. Smith, who took over Upstate in September 2006.

Dr. Smith and other officials at University say that the patient safety statistics are misleading because they do not fully capture the fact that the hospital treats very sick patients.

Dr. David Duggan, an associate dean at Upstate Medical, said that other surveys show that University Hospital’s patient safety record is generally on par with other hospitals. “There are some areas where I think we are above average,” Dr. Duggan said, “and other areas where I think we need to work.”

In his battle to keep University independent of Crouse, Dr. Smith had a powerful ally: the hospital’s unions. Most hospital employees in New York, including those at Crouse, are represented by Local 1199. But those at University are represented by state employees’ unions, which have richer contracts than 1199. In 2007, University Hospital received a state subsidy of $42.2 million, about $2,500 for each patient it admitted, to make up the difference. Not surprisingly, University unions paid for television advertisements, lobbied lawmakers and filed a lawsuit to overturn the recommendations.

Within Syracuse, University also had support. The medical school and hospital are by far the largest employer in the city. “They employ people at decent jobs,” said James Tallon, the president of the United Hospital Fund, a nonprofit group that studies health care in New York State. “And the money comes from Washington — money comes from elsewhere.”

By spring 2007, the state Health Department backed off the plan to join University and Crouse, saying both could remain open and independent.

But Mr. Berger, whose commission had no authority after it filed its report in late 2006, says the public would be better off if the state had followed its recommendation by folding University into Crouse.

“The place that I’m most unhappy about,” he said, “is Syracuse.”

The Errors Snowball

Sharon Yacketta, 56, has not had an easy life: four brief marriages, three children given up for adoption, six months in jail for welfare fraud. She lives in a two-room apartment near downtown Syracuse, with dingy gray carpets and a hulking black television.

On March 12, 2004, she entered University Hospital for an operation by Dr. Lai to relieve her incontinence. But during the surgery, a suture punctured her right ureter — the duct connecting the kidney to the bladder — and urine began leaking into her abdomen, according to a lawsuit she has filed against University that takes its details directly from her medical records.

Then the errors snowballed, according to the complaint, which lays out in flatly clinical language three years of suffering.

Ms. Yacketta suffered near-fatal infections, endured severe pain and watched in horror as urine and stool leaked from her body. Since the first surgery, she has had at least 19 operations. In October 2005, she moved to St. Joseph’s Hospital, which by many measures is the highest-rated hospital in Syracuse.

Since then, she has been under the care of Dr. B. Sivikumar, director of St. Joseph’s surgical intensive care unit. Dr. Sivikumar said that Ms. Yacketta’s continuing problems were very likely caused by the initial operations at University.

After examining Ms. Yacketta’s claims, Dr. Jonathan Fine, a retired internist and founder of At Your Side, a nonprofit group that trains volunteers as bedside advocates for patients, said University had repeatedly made preventable errors in her care.

“This case alone merits, from ground up, a total revamping of the procedures that are in place in that hospital, and the culture of the hospital,” Dr. Fine said.

Dr. Duggan said he could not comment specifically on Ms. Yacketta’s suit but cautioned against reading too much into any one case. “We are not going to be able to prevent every problem from occurring,” he said.

Other lawsuits, and reports from the state Health Department, also point to problems at University. A 2005 state report refers to a case of surgery on an infant in which “generally accepted standards of professional care were not consistently provided,” leading the infant to be discharged prematurely and return in less than 48 hours with kidney failure.

Another report, after a surgery in December 2006 in which doctors operated on the wrong part of the body, criticizes the hospital for failing to make changes promised after another “wrong-site surgery” two years before.

Dr. Smith said he had made patient safety a priority for University. “It is a major focus of this institution,” he said.

But without faster and more accurate data gathering, no one outside University — or any other hospital — can know whether it is doing a good job, or penalize it if it is not, said Dr. Donald Berwick, the president of the Institute for Healthcare Improvement, a national nonprofit group trying to reduce hospital mistakes.

“We need to act with more speed and diligence to stop practice where it’s actively harmful,” Dr. Berwick said. “Let the needs of patients come first, not the needs of a hospital.”

This article has been revised to reflect the following correction:

Correction: December 11, 2008
A chart on Monday with the continuation of an article about the difficulty of closing or shrinking hospitals despite evidence that they are providing costly and below-average care carried a headline and caption that did not fully reflect the range of data in the chart, which focused on University Hospital in Syracuse. The data, headlined “Falling Short in Syracuse,” showed that University ranked above the state average in terms of providing treatment to prevent blood clots 24 hours before or after surgery and that the hospital was virtually even with the national average in the number of heart attack patients who died within 30 days. The data did not show only areas in which University Hospital fell below state and national averages.

The chart also misstated the date for the mortality rates shown. Those statistics were for July 2006 to June 2007, not for all of 2007. A corrected chart is at nytimes.com/evidencegap.

By Alex Berenson

Copyright 2008 The New York Times Company

Source: http://www.nytimes.com/2008/12/08/business/08hospital.html?_r=1&scp=7&sq=hospitals&st=cse

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