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| ▲ | somenameforme 2 days ago | parent | next [-] | | This is not entirely clear. Elsewhere in this thread I found a couple of studies on this exact topic. The first [1] is just for breast cancer and after normalizing across a wide array of variables, found no improved survival rates except for black women, which I think is suggestive of further biases. The second [2] is for all sorts of cancers, but is a large observational study without much effort to control for biases. It found an overall increase in five year survival rates of 3.6% (64.3% in NCI centers, vs 60.7% in non-NCI). That's certainly something, but it's fairly certain that biases would bring that down a healthy chunk. However there were significantly better outcomes in more rare/lethal cancers. For instance in hepatobiliary cancers, the NCI survival rate was 33.8% vs 18.7% for non-NCI centers. And that is largely the point I'm making. For the overwhelming majority of things, care is mostly commoditized and you will be fine wherever you go. The value of high end institutions is mostly only realized in the case of rare/serious issues, for which transfer is always an option anyhow. --- Though I'd also add here that these examples, cancer, are on the fringe extremes of what my point was. That there is a strong argument to be made that even cancer falls within it, just further emphasizes the point. If your local hospital can competently treat cancer, they can certainly treat the overwhelming majority of reasons people go to the hospital, which are relatively far more commoditized. [1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8462568/ [2] - https://pmc.ncbi.nlm.nih.gov/articles/PMC4892698/ | | |
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| ▲ | epcoa a day ago | parent | prev | next [-] | | "can competently treat cancer, they can certainly treat the overwhelming majority of reasons" No this claim, just because, is not weight-bearing. Extraordinary claims require extraordinary evidence. And I don't understand the motivation to make such a tenuous link when at a bare minimum one can look up direct data like joint commision and MPSMS safety data and related publications. There is tremendous variability in serious hospital safety events inter-institution for bread and butter admissions. One can further just examine CMS and NHS data for mortality and readmission for "mundane" MI, HF, sepsis, pneumonia, respiratory failure. OB/GYN outcomes are their own thing. The flaw in reasoning here is that quality of care and outcomes is strongly related to the simplicity of diagnosis. A further flaw is the belief that care is "commoditized". Treatment protocols vary widely across institutions and health systems, often times based on cost factors. Certain basic things can not be done at night, or even the day for fully accredited hospitals. There's a big difference somewhere with 24 hour anesthesia airway and in-house surgery and not just an intensivist "on call" 600 miles away and staff that can't even do RSI. Transfer is not always an option, there's a reason critically ill people die more frequently in the sticks. If one is admitted to a regional hospital, they are unlikely to be accepted for transfer to a safer hospital unless they truly need an intervention that absolutely cannot be provided where they are, not simply because there is better backup provider support and a higher standard of safety. They will still remain at that higher risk for sepsis, or outdated care because the community physician group doesn't keep up with guidelines, or that hospital only offers the inferior treatment (or a limited formulary) for cost-cutting reasons. Breast cancer and most cancers are not even typical inpatient encounters. Breast cancer is generally not managed on an inpatient basis, in fact one may never even have to visit an inpatient hospital campus for breast cancer. Upgrades for cancer are usually different than acute inpatient care. Breast cancer does not usually involve abdominal, intrathoracic or orthopedic surgery. Breast cancer does not usually involve advanced interventions like endarterectomy, ECMO. Cancer is a special case. Regardless of complexity, extrapolating cancer treatment to even the most "mundane" acute inpatient or surgical care really is beyond ridiculous. This is a complex subject and this is a silly hot take. | | |
| ▲ | somenameforme a day ago | parent [-] | | Again, feel free to provide data instead of lighting strawmen alight. In general you are already speaking of things that are primarily relevant for people critically ill in senescence, which is both a fringe scenario and also (I think obviously) not the general case sort of scenario I'm speaking of. But even there! Out of curiosity, I decided to look up data on e.g. sepsis readmission rates vs hospital quality. [1] --- "One third of sepsis survivors were readmitted and wide variation exists between hospitals. Several demographic and structural factors are associated with this variation. Measures of higher quality in-hospital care were correlated with higher readmission rates. Several potential explanations are possible including poor risk standardization, more research is needed." --- As they're implying, this is likely due to biasing and not a causal observation. One possible explanation is that higher quality hospitals may be able to keep people knocking on deaths door a bit longer than lower quality hospitals, but it's not like night and day - they're still knocking on that door, just a bit longer. And so it makes sense that they'd actually have worse outcomes on discharge, including higher overall readmission rates. But once again the picture between the quality of hospitals is not this tremendous dichotomy that many try to frame it as. Billionaires, in general, seek out the highest quality care money can buy, and have no limitations on the meta-factors that also improve longevity including activity, relationships, healthy food, exercise, etc. Yet their life expectancy (~85) is comparable to the life expectancy of Hispanics in America. The "Hispanic Paradox" [2] again emphasizes that longevity isn't about premium healthcare and money. [1] - https://journals.lww.com/ccmjournal/abstract/2017/07000/seps... [2] - https://en.wikipedia.org/wiki/Hispanic_paradox | | |
| ▲ | epcoa 16 hours ago | parent [-] | | https://pubmed.ncbi.nlm.nih.gov/28060228/ MI, HF, sepsis, pneumonia, respiratory failure are among the most common reasons for inpatient admission, not fringe. Equating acute decompensation of chronic illnesses requiring inpatient admission to "knocking on death's door" is a bit simplistic. No data has been provided showing how the relevance of outcomes based on institution of first presentation (not definitive management) for breast cancer, that is usually managed outpatient on an elective basis, has anything to do with outcomes for the "overwhelming majority of things people to go to the hospital for". Even pre-pandemic the life expectancy of Hispanics was not as high as billionaires. Speaking of "deaths door" perhaps at least QALY, or something else is a more appropriate metric. | | |
| ▲ | somenameforme 13 hours ago | parent [-] | | Cheers on the study! Let me first describe what I meant by fringe though. Take a random adult going to the hospital, not elderly, with no other major health conditions. When he walks in the door, what are the distributions of issues that he might end up having? Sepsis is going to have a probability of near 0. By contrast the typical patient that might present with sepsis - elderly, other major health conditions, well into senescence - he is generally indeed 'knocking on deaths door.' He might not answer this time (though there's a decent chance he will!), but he will imminently. Your study compared hospitals based on a number of factors. The most significant was high volume, but in that case the difference between the highest volume hospitals and lowest was a 13.3% rate of readmission vs a 11.2% rate of readmission for hip replacement, and 12.4% vs 11% for knee replacement. Again I think this is another example of when you look at the actual data, outcomes fall quite close. Beware their method of taking a sampling and breaking it into buckets and comparing those buckets. If even hospitals/patients were identical (which I'm certainly not claiming) and so the results were literally just random noise on a distribution, you'd see a major difference between the top and bottom buckets due to the nature of random distributions - 68-95-99.7 and all that. Their results show a signal beyond that, but it's generally a very misleading way of presenting data because of this issue. Pre-pandemic hispanics had a life expectancy of about 82, which I described as comparable to the 85 of billionaires. I'd certainly expect billionaires to be higher for the endless reasons outlined in the already linked Hispanic paradox. The fact that it's only 3 years, less than 4% longer, is the point. |
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| ▲ | somenameforme 2 days ago | parent [-] | | This is not anecdotal. At least for the cancer we're discussing, breast cancer, there is no meaningful difference between hospitals. Here [1] is a study on this exact question for breast cancer. They covered an extensive number of variables across hospitals and patients (including NCI/ACS status). They found no correlation with improved survival rates for any variable except for black women receiving their initial treatment at an ACS hospital. While that is technically an affirmation of your claims, I think it is clearly suggestive of some form of bias rather than being a clear causal association. [1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC8462568/ | | |
| ▲ | epcoa 2 days ago | parent [-] | | . | | |
| ▲ | somenameforme 2 days ago | parent [-] | | I said for the overwhelming majority of things people go to the hospital for. And the overwhelming majority would be things far more commoditized than cancer - stomach aches, injuries, fevers, infections, cardiovascular issues, etc. I chose breast cancer because it is the most common type of cancer and at the extreme fringes of my what comment might cover. It just so happens that my comment does cover it as well. Incidentally, it's also the same story for colorectal cancer, the 2nd most common type of cancer. Here's another study on the topic. [1] They have a survival rate of 88.6 vs 85.9 for breast cancer, but it's a large observational study that's not normalized, so the confounders/biases there probably explain the reduction in survival rate at non-NIC hospitals. Colorectal cancer is even smaller - 0.2%. NIC hospitals only showed a significant effect on cancers with low survival rates, and especially on rarer cancers. For instance with pancreatic cancer 93.8% of people who went to a non-NIC hospital were dead in 5 years, by contrast 'only' 87.5% of NIC hospital patients were. Feel free to look up the data yourself. I'm not searching for cherry picked studies, there are none - as there seem to be oddly few studies on this question, and they all say the same thing. What benefit there is is quite small, and heavily driven by extremely rare things. [1] - https://pmc.ncbi.nlm.nih.gov/articles/PMC4892698/ | | |
| ▲ | epcoa 2 days ago | parent [-] | | . | | |
| ▲ | somenameforme 2 days ago | parent [-] | | Feel free to find a single study that you think supports your position. I've provided extensive evidence for my claims which you want to claim is insufficient or somehow cherry picked. You've provided nothing, and are now relying exclusively on ad hominem. | | |
| ▲ | epcoa 2 days ago | parent | next [-] | | Two registry cohort papers on breast cancer outcomes, one only in Los Angeles county "provide extensive evidence for my claims" The claim: For the overwhelming majority of things people to go to the hospital for, where you go doesn't really matter. You win, as always. https://news.ycombinator.com/item?id=45199654 | | |
| ▲ | somenameforme 2 days ago | parent [-] | | You chose to take us down the path of cancer, not entirely unreasonable as I mentioned it. But it is clearly in the fringe extremes of my argument since it is one disease where, ostensibly, specialized care could really pay off. But it turns out that even in the case of cancer, the benefit of specialized care (for the most cancers at least) is small to zero. If your local hospital can treat e.g. colorectal or breast cancer to the same degree as a specialized institution, then they can certainly competently treat the overwhelming majority of other issues that people show up to the hospital with, which are generally going to be substantially more mundane with rather more 'commoditized' treatment available. |
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