​
This page helps you find doctors and nurse practitioners who spend more time with each patient. More time has 3 benefits: They listen and examine you in more detail. They've listened and examined other patients in more detail, so they've learned about diseases in more depth and breadth than at medical school. They can minimize their own burnout, which affects half of doctors in internal medicine, family medicine, and ob/gyn.

Later, when you know specific treatments you need, you can use a different page to see which specialists have the most experience with each procedure.

1. ​Doctors who Serve 3 Settings These are the few thousand general practitioners who treat patients in the office, hospital and nursing home. Most doctors no longer visit hospitals, and even fewer visit patients in nursing homes. The doctors on the map give continuity of care when their patients need a hospital or nursing for major illnesses. You can decide if one of these is right for you.
   
2. Geriatric Medicine specialists. There are not many of these, but they may be helpful for older patients, even for a consultation.
3. Doctors Making House Calls to homebound and Assisted Living. These can be helpful for patients who cannot get to a doctor's office, though Medicare will fine them if they falsely certify a patient is homebound. Some apps may have additional doctors, and Medicare plans to allow more house calls in 2019.
4. Hospitals This does not list doctors, but has specialized hospitals, such as cancer, children, long term care, psychiatric, rehabilitation and VA
5. Nursing Homes also does not list doctors, and so far only covers a few states, but full list, where you can select your state, is here.

You can call any doctor's office to see which hospital and nursing home they visit. You can also check patient reviews, malpractice, etc. as discussed in STEP C of the specialists page. Maps 1 and 3 include Family and General Practice, Geriatric and Internal Medicine, Nurse Practitioners and Physician Assistants, but they omit Ob-gyn, since Ob-gyn data don't show place of treatment.

Spreadsheets list all the doctors. Choose the USA (SLOW ! 142 megabytes; save it  so you don't have to download it again), or Maryland, DC and nearby Virginia (4 megabytes). They show you:

• Doctors who give 45-60 minutes for a first appointment.
• Doctors who average 25 or 30 minutes or more for subsequent appointments.
• Appointment lengths for other doctors, including yours.
• Length of doctor visits in hospitals and nursing homes.
• Which doctors and nurse practitioners also go to assisted living or even home visits.
• The file is based on Medicare data for 2015.

You may not always need long appointments, but doctors with long averages, and their schedulers, at least offer long appointments when needed. Longer appointments include more extensive medical history, cover more severe problems, with more complex medical decisions. 

To find doctors near you, in a specialty, and/or male/female, you can filter the spreadsheets (click an arrow in 3rd row). For example column G shows the state:

1. Click "Enable Editing" if it asks at the top of the screen
2. Click the arrow in the 3rd row of Column G
3. Unclick "Select All"
4. Click the state(s) you want
5. Click OK, and you will see providers in the state(s)

You can also filter on specialty, city, zip code, male or female. To help you find nearby areas, there are maps of 5-digit zip codes, the first 3 digits of zip code, and the first 2 digits, or here. On the map of 3-digit zips, move to new areas by clicking the N, S, E, W arrows, then zoom in; you can see anywhere in the country on their free demo. All of a doctor's appointments are listed at one address, which the doctor provided to Medicare, even if the doctor has multiple locations.

Length of office appointments is based on the typical face-to-face time. Hospital and nursing home visits include both face-to-face time, and time dealing with that patient's needs on the hospital floor or at the nursing home (as explained on p.18 of a presentation). The median hospital doctor claims to spend 16 minutes with each patient. Some audiovisual telehealth contact is also covered (p.31 of the same presentation). Time talking to the family with the patient not present is not covered. Length of appointments at home and in assisted living seems to be face-to-face time.

Medicare will pay for more tele-medicine in 2019. Medicare "telehealth" has been restricted to non-metropolitan areas by 42 U.S. Code § 1395m(m)(4)(C)(i), also called 1834(m), but Medicare is defining "communication technology–based services" to pay $14 for short interactions, while cutting pay for office visits to keep the overall budget the same.

You can select male or female, but some specialties have few women.

The spreadsheets also help you find local doctors who give continuity of care by treating their patients in all 3 settings: office, hospital, and nursing home. If you've been hospitalized, you know the difficulty coordinating between your personal doctor and hospital doctors. Life is easier and care may be better if your personal doctor can treat you in the hospital.

A 2017 study shows that hospital patients where the hospital let their personal doctor treat them, had a better survival rate (91.4%) than patients treated by hospitalists (89.2%). The extra 2.2 percentage points mean that for every 45 hospital patients treated by their personal doctor, one more person was alive 30 days after the hospital stay. The map and spreadsheets (USA or DC area) show which doctors and nurse practitioners do treat patients both in and out of hospitals:

• Number of office visits they did in 2012-2014 (for Medicare)
• Number of visits to hospitals in the same years. You can click here to find which hospital the provider uses, to see if it will satisfy you. That site also gives you phone numbers, so you can call providers' offices to confirm the hospital, and find which nursing homes they visit.
• Number of visits to nursing homes
• Number of visits to assisted living. This matters if you are in or may go to assisted living
• Number of home visits. This matters if you are home-bound.

• Ob-Gyn (pelvic and clinical breast) exams are separate; time estimates and locations are not available for these

​A 2017 JAMA article says, "In an ideal world, primary care physicians would follow their patients from the office to the hospital and to the nursing home. This would improve continuity of care and increase the chances that the patients’ preferences, generally better known by the primary care clinician than a new clinician, are respected..." 

On the other hand you can also see the much bigger numbers of providers who specialize and just provide hospital care, office care or nursing home care.

Primary care doctors in hospitals and nursing homes provide basic ongoing care, in addition to specialists and surgeons who provide their specialties. Some hospitals use their own staff "hospitalists" to provide primary care.

​Primary care billing in hospitals (among 49 million Medicare visits billed in 2015):

• 62% of hospital visits are by the 38,522 doctors who do over 90% of their work in hospitals (hospitalists)
• ​7% of hospital visits are by the 4,404 doctors who do 10% or more of their work in each setting: office, hospital, and skilled nursing facility (SNF)*
• ​24% of hospital visits are by the 24,033 doctors who work in office and hospital, but not in SNFs (<10% of their workload)

​Primary care billing in skilled nursing facilities (SNF, among 13 million Medicare visits billed in 2015):

• ​29% of SNF visits are by the 2,866 doctors who do over 90% of their work in SNFs (SNF specialists)
• 22% of SNF visits are by the 4,404 doctors who do 10% or more of their work in each setting: office, hospital, and SNF,* so they can follow patients to each setting
• 27% of SNF visits are by the 5,688 doctors who work in office and SNF, but not in hospitals (<10%)
• 13% of SNF visits are by the 2,565 doctors who do 10% or more of their work in hospitals and 10% or more in SNFs, but under 10% in an office, so they can follow patients between hospital and SNF
• 4% of SNF visits are by the 381 doctors who work in in SNFs and assisted living, but not office or hospital (<10% each), so these doctors can follow patients between assisted living and SNF

* ​For these doctors who work in all 3 settings, on average 42% of their practice is in their office, 31% in hospitals and 26% in nursing homes, so they are experienced in each setting.

​Many physicians have offices close to a hospital, and some devote a day each week to one nursing home, so patients who choose that hospital and nursing home can see their personal doctor if the institution allows.

These percents include Family and General Practice, Geriatric and Internal Medicine.

The spreadsheets have a web link for each doctor, to copy into your browser. It takes you to a consumer rating site, which also takes you to the doctor's website if they can find it. There are helpful hints for using large spreadsheets like this.

You can supplement these bare numbers with all the sources on patient reviews, malpractice, etc. discussed in STEP C of the specialists page.  
​
Some patients want to know who is independent of the hospitals and Accountable Care Organizations (ACOs) which have been absorbing most practices, so they can have independent advice. Lists of doctors who are independent of the major health systems are at: aid-us.org/directory, Idaho, Georgia, New York City, Minneapolis-St. Paul, south Charlotte, . Some groups with "independent" in the name are ACOs with incentives to refer to each other. Insurers also pay incentives to doctors to meet financial goals.

Home Visits: Medicare and other insurance plans pay for home visits when there is a reason, such as letting the doctor assess the home situation, coordinating with home caregivers, or difficulty getting to the office. A doctor describes the emotional benefits he gets from even doing a few home visits per week. Doctors are paid more for home visits than office visits, so copays may be higher too. The spreadsheets described above show names and locations of 4,000 US doctors who do more than 2 home visits for Medicare per week (104/year), so you can find one near you. 1,300 of these doctors do more than 10 home visits per week (520/year). An association of doctors advocates for the service, and also has a referral list of about 300 doctors and groups. There are some experimental programs to save money by deterring seriously ill patients from going to hospitals.

Source: The spreadsheets use Medicare data. They are useful for non-Medicare patients too, since they show differences among doctors even if you are young or privately insured. Doctors who work only for managed care plans, like Kaiser or Medicare Advantage (Part C), are not included, so you will need to look elsewhere. Medicare does not release counts of 10 or fewer patients, to protect privacy, so there is little data on doctors who see few Medicare patients. Address cleaning provided by Texas A&M University GeoServices

Earlier spreadsheets showed:

• ​2012-2014 data for USA (129 megabytes) and DC, MD, and nearby VA (4 megabytes).
• 2013 data for USA (199 megabytes), or DC, MD, and nearby VA (7 megabytes), with more detail on each type of appointment

The first column has an overall rank you can adapt. It looks for the highest values on 5 items:

1. Average length of initial, subsequent and nursing home/hospital visits, to show which doctors spend time with you (multiplied by 6 to scale the minutes for comparability with other items).
2. Number of hospital visits, to show which doctors can follow you into the hospital.
   
3. Number of nursing home visits, to show which doctors can follow you into a nursing home.
   
4. Office visits as % of hospital visits. When this is over 100% or 200%, it highlights doctors whose primary loyalty can be to patients, not the hospital.
5. Office visits as % of nursing home, again to highlight doctors who focus on patients in the community, not just those in nursing homes.

The rank looks for doctors who are high on all 5 items. Change it if something else is important to you. An article in Becker's Hospital Review discusses how hard it is to get even 25 minutes from many doctors, but this list shows the doctors who regularly spend that much time with patients.

The spreadsheet shows

• Average bills for doctors' appointments and visits, in case you need to go without insurance
• Average amount Medicare allows, which may be a guide to what you can bargain for, or what other insurers pay. Medicaid usually pays less, and many doctors don't accept Medicaid.

• Number of office appointments for new Medicare patients (col. V). This shows if the doctor is taking new patients. If it is less than 12 or 24 (1 or 2 new Medicare patients per month), the doctor may not have room to take you. You can also compare it to the total number of office appointments (col. O), to see if the doctor has a lot of turnover The number of new patients is high for doctors who see many patients just once, for consultation, or because patients don't like them. There are also some surgeons in the list who show primarily initial office visits, since follow-up care is covered by the surgical fee, and is not billed separately and not listed separately here. Surgeons with a lot of subsequent appointments may be trying non-surgical approaches first. For psychotherapy, new patients cannot be identified separately, so they are all listed as subsequent appointments. A new patient means the doctor has not seen the patient in the past 3 years, and neither has any other doctor in the practice who has the same specialty and subspecialty. 
• The 2013 spreadsheets show total hours per week each provider billed to Medicare for these appointments and visits. If this is useful I can add it to the 2012-2014 file too. You can ask the provider's office how much non-Medicare work they do, to see if the total hours are reasonable. Up to 40 hours or so for Medicare may be reasonable if they have mostly Medicare patients, but could show an overloaded doctor if younger patients are also getting a lot of care. Remember they have many hours administering their practice and keeping up with knowledge, besides the billable hours. 62% of doctors spend less than 46 hours per week seeing all patients, Medicare and others; 82% spend less than 56 hours per week seeing all patients.

Some who bill very high hours may include other staff in their data. Then you won't know what to expect from the specific person you see; for example they could have separate staff for office and hospital work. Usually each doctor, nurse practitioner, etc has a unique number and a separate line in the spreadsheet. Multiple staff are more likely if the specialty is "Multispecialty Clinic/Group Practice" or if the name is ALL CAPS, which means Medicare called them an "office" not an "individual."

Besides averages, the 2013 spreadsheets show the number of visits by length: 10 minutes, 30 minutes, 60 minutes, etc. Medicare does not estimate time for the annual wellness visit, so I estimated the time based on what they pay, compared to what they pay for regular visits of 25, 40 or 60 minutes. These estimates are 48 minutes for an initial wellness visit and 29 minutes for a subsequent one, and appear separately in the spreadsheet, so you can use other estimates if you wish. There are also physical exams in the first 12 months of Medicare enrollment, which are grouped with the initial wellness exams at 48 minutes. ProPublica shows graphs of how many subsequent appointments at each length each doctor gave in 2012, though one cannot search for doctors who give long appointments. They consider long appointments a cost problem, not a patient benefit.

Each column in the spreadsheet summarizes several billing categories. A summary page lists all the detailed categories, how common each is, national average costs, and Medicare's estimate of how long it takes.

In October 2015, Medicare released information on types of Medicare patients seen by each doctor, to show which doctors are most familiar with these types of patients. The information can be added to the doctor files, but would make the files even bigger. A private insurance app suggests that some patients do want to find doctors who treat patients who are similar by age and gender. Comments are welcome below.

Patient age is calculated at the end of the calendar year or at the time of death.

• Average age of Medicare patients.
  
• Medicare patients with disabilities under age 65.
  
• Number between 65 and 74.
• Number between 75 and 84.
  
• Number over 84.

Number female.
Number male.
Race is based an algorithm that uses Census surname lists and geography to improve the accuracy of race/ethnicity classification, particularly for those who are Hispanic or Asian/Pacific Islanders.

• Number of non-Hispanic white beneficiaries.
• Number of non-Hispanic black or African American beneficiaries.
• Number of Asian Pacific Islander beneficiaries.
• Number of Hispanic beneficiaries.
• Number of American Indian or Alaska Native beneficiaries.
• Number with race not elsewhere classified.

Number who had no Medicaid benefits in the calendar year.
Number who had Medicaid sometime in the year
Conditions (based on algorithms used at http://ccwdata.org/index.php)

• % with Alzheimer’s, related disorders, or dementia.
• % with Asthma.
• % with atrial fibrillation.
• % with cancer. Includes breast cancer, colorectal cancer, lung cancer and prostate cancer.
• % with chronic kidney disease.
• % with chronic obstructive pulmonary disease.
• % with depression.
• % with diabetes.
• % with heart failure.
• % with hyperlipidemia.
• % with hypertension.
• % with ischemic heart disease.
• % with osteoporosis.
• % with rheumatoid arthritis/osteoarthritis.
• % with schizophrenia and other psychotic disorders.
• % with stroke.

Average Hierarchical Condition Category (HCC) risk score of beneficiaries. Beneficiaries with score over 1.08 are expected to cost more than the Medicare average, and vice versa.

• Risk scores are based on age, sex; use of Medicaid, whether a disability before 65, qualified for Medicare, in institution (usually a nursing home); and diagnoses from previous year. The risk model was designed and is more accurate for large groups, such as the enrollees in an HMO.
• CMS uses HCCs to determine the diagnosis-related portion of the risk score. For example, the HCC system for 2010 included a total of 189 conditions, with related conditions grouped into 70 disease hierarchies. One hierarchy had three different diseases that affect the liver: end-stage liver disease, cirrhosis, and chronic hepatitis. Each condition had a weight that reflects its marginal contribution to a beneficiary’s total expected Medicare costs.
• Under the HCC system, CMS calculates the diagnosis-related portion of a beneficiary’s risk score by adding up the weights for the most severe diagnosis that the beneficiary has in each disease hierarchy. Continuing the example above, a beneficiary with both cirrhosis (weight = 0.406) and chronic hepatitis (weight = 0.406) would receive credit only for the cirrhosis diagnosis. The researchers who developed the HCC system adopted this approach after finding that having multiple conditions within a hierarchy did not increase overall patient spending substantially.

 
To protect the privacy of Medicare beneficiaries, the number of beneficiaries fewer than 11 have been suppressed and the percent of beneficiaries between 75% and 100% have been top-coded at 75% .

Many people know someone who has had a knee replacement. Many people think about getting one and look for a specialist. The medical term is "Total knee arthroplasty." The UpToDate article on it starts by referring readers to medical management of rheumatoid arthritis, and also cites a range of surgical options. The next paragraphs discuss knee replacement, because it is well-known, not because replacement is the first choice. 

The 2012 D25 file (described in the Box) shows that the 20 highest volume Medicare providers are spread all over the country, in 13 states: Alabama, Arkansas, California, Colorado, Florida, Georgia, Illinois, Missouri, New Jersey, Oklahoma, South Carolina, Tennessee, and Texas. The 2013 file shows an overlapping list of doctors with high volume.

The websites of these high-volume doctors are worth exploring. If one of them accepts your insurance and you live nearby or have friends where you can stay during the long recuperation, you can consider going there. 

Dr Bassett in Harlingen Texas has the highest volume in 2012 with 434 knee replacements. His website has a variety of information from Biomet (which makes joints). His website also says he teaches at the U of Texas, so many of his surgeries are likely done by residents. Consumer sites have several good reviews and one complaint about delays getting a cortisone shot. Dr Dearborn in Fremont California is second with 411 knee replacements. His web page does not say that he teaches; it does have a 10-page pdf description of alternative ways to do the operation and some of its risks. Two of his 12 written reviews on Vitals and one of 20 on AngiesList describe failed surgeries; the others describe successful outcomes or consultations

Wherever you live you can also look closer to home. For eample in the Washington DC region, Dr Dalury north of Baltimore did 211 knee replacements in 2012, and he teaches. Vitals mentions long waits for appointments, but all the consumer sites have praise and no complaints about outcomes. ProPublica says his patients have an average rate of readmissions to hospital within 30 days after surgery, for causes which could be related to the surgery. Checkbook does not list him.

If he is too far and you can accept doctors who do 2 per week instead of 4-8 per week, you can look in the immediate area around Washington (zip codes beginning with 20). The 2012 East file (also in the Box) shows the largest practices are Dr Cannova in Bethesda MD with 120 knee replacements, or Dr Peyton in Sterling VA with 88; neither teaches. One of many written comments on Dr. Cannova complains about a brief appointment and his approach, so the patient went elsewhere; otherwise much praise and no complaints about work he did.  ProPublica found an average rate of readmissions for him, and says he operates at Suburban and Sibley hospitals. 14 of the 31 reviews for Dr Peyton complain about rudeness or long waits in the office to see assistants, little contact with the doctor, even in the hospital. Some of the positive reviews also say contact is generally with assistants; several express happiness with his surgery. ProPublica found a high rate of readmissions for him, and says he operates at Reston. Checkbook does not list Cannova or Peyton.

You can also search ProPublica and/or Checkbook for knee surgeons with low rates of readmission (and other complications at Checkbook). See Section B on another page. Remember that the major result, how well knees work after surgery, is still unknown, so you may want references and higher volume doctors within those lists, to try for the best knees, not just the lowest complications. You can search ProPublica by state. Maryland shows several hospitals, with graphs showing results of individual doctors. The lowest (best) point is in Annapolis, and when you click there, you find Dr. McDonald has lowest readmissions and the hospital billed for 782 knee replacements by him from 2009-2013 (5 years). He could be worth exploring. The Globe1234 files show he billed Medicare for 156 knee replacements in 2012 (deast), and 169 in 2013 (doc13sm). Dr. McDonald did not show up in the previous paragraph, based on zip codes beginning with 20, since his zip code is 21401. 

You can search Checkbook by distance from a zip code. Searching within 75 miles of 20001 (downtown DC), it shows 13 knee surgeons with the lowest "bad outcomes", and you can click each one to see if volume is above average. They do not show detailed numbers on quality or volume, but you can get volume from this site or ProPublica. Dr. McDonald shows well there too. Checkbook's strength is its more thorough count of complications than elsewhere.

Some doctors' websites say why they recommend certain brands of knee joint. When patients see a doctor they can ask about the brands and approaches they have found on other doctors' sites.

These examples show the variation in patient comments, use of residents, and volume, which you might find in any field. Each patient or referring doctor can similarly search for Pain Management, Rheumatology and other specialties to find alternatives, though it is hard to be thorough when you are in pain or worried. If none of the first doctors you evaluate seems good enough, it's always possible to go back to the spreadsheets and find more candidates to consider. Second opinions help too. One patient said he went in to see about knee replacements, and the doctor said those could wait, but he needed 2 hip replacements, which he got and both went well. A a 2nd opinion would definitely seem appropriate.

Medicare and ProPublica tell you what payments each doctor received from medical companies. Biomet paid Dr Peyton $46,000 in royalties, so he may be quite expert on Biomet's joint. Patients need to decide if relationships with medical companies will strengthen or weaken their care. DocFinder and Pacer are ways to search for legal actions against any doctor you consider.

Your correspondent does not know or have any relation with any of these named doctors, and has been fortunate not to need a knee replacement, so there is no personal knowledge or bias here.

RETURN TO ARTICLE ON FINDING HIGH-VOLUME SPECIALISTS

While investigations proceed, consumer reviews provide one way for potential patients to hear about concerns. Other doctors in the area may be another source, but 60% of male doctors and 67% of female doctors do not necessarily tell patients when another doctor is substandard (they fear retaliation). 9% of doctors do not tell patients about mistakes which harm them.

Some state boards provide information on malpractice suits as well as disciplinary actions in the DocInfo  and DocFinder lists, but usually patients have to search the web or state court records. Each state has its own system for searching court records. and there are good search functions in private newsletters in CA, FL, IL, LA, MO, PA, TX and WV which report civil cases. Half of all doctors have been sued for malpractice. Half these doctors who were sued were dismissed from the case before or after trial. 96% of the cases gain money for the plaintiff, often by settlement, without a finding of who was right, since the participants cannot predict which expert a jury will believe. 

Private groups collect information, including TruthMD, LexisNexis and PreCheck.

Lawsuits against makers of drugs and devices are summarized at DrugDangers.com, which is maintained by a law firm. Most are in state courts.

Federal court records (such as Medicare fraud) are easily searchable at Pacer (Public Access to Court Electronic Records, 10 cents/page. $2.40 per audio file of court hearings). Even malpractice cases can appear in federal court when patients and medical suppliers are in different states.

A free archive holds many Pacer records, and Pacer cancels costs under $15 per calendar quarter, so you can do most simple searches without cost.

The doctors indicted by Medicare's fraud team appear in Pacer. The highest-volume surgeon for knee replacements is in Pacer as a co-defendant in one federal case in 2014, which became part of a settlement agreement. Patients can ask for information and decide if it matters to them.

The weight loss surgeons reported by the LA Times are in Pacer because of a 2012 whistleblower suit and a suit by the same surgeons against a health insurer. Of two doctors named in the NY Times article on heart surgery, one is in Pacer since he sued the hospital for suspending him; the other is not. The spine surgeon reported by the Washington Post does not appear in Pacer, since the whistleblower suit was filed against the hospital. The three surgeons named by USA Today all appear in Pacer. The cardiologist named by the Justice Department in 2015 appeared in Pacer starting December 22, 2014.

Thus Pacer provides a lot of information, though not a complete list of problems. Searches cost 10 to 50 cents, depending on length. Once you find a case, the "Case Summary" tells you the parties and their lawyers; the "History/Documents" lists documents. I usually click that and then select "Only events with documents" and "Display docket text." From the resulting list you can click the number in front of any document to see its cost and decide whether to view and print it. There's no extra cost for going back to look at a document you already paid for in the same session, though repeating a search costs money, since they do a new search each time.

There is a far more complete list of problem doctors which Congress does not want you to see. The National Practitioner Data Bank lists "800,000 license and hospital disciplinary reports and past malpractice payment reports for clinicians" 1990-2014. Congress forbids showing the list to patients or referring doctors. The federal government shows the list to those it thinks "need to know the most - the hospitals that are considering hiring [doctors] or the licensing board." Malpractice attorneys point out its gaps, but still would find access useful in building cases. There is a public version without names and addresses if you agree to their Data Use Agreement, and a 2011 version without that agreement, but still lacking names and addresses. The size of the list ranges from 900 adverse actions in Hawaii to 50,000 in Texas over the last decade. Several reporters have used the list for stories. Public Citizen used it to summarize doctor's sexual misconduct, and found that Canada has much better reporting and that many state medical boards let doctors continue to practice after hospitals discipline them. It is important to note the Veterans Health Administration does NOT report many disciplinary actions to this National Practitioner Data Bank, so there is no central record of doctors they have disciplined or fired.

Most state medical boards do not search the National Practitioner Data Bank when they license doctors.

RETURN TO ARTICLE ON FINDING HIGH-VOLUME SPECIALISTS

Do Not Resuscitate (DNR) means that if the heart stops, the patient does not want Cardio-Pulmonary Resuscitation (CPR) to try restarting the heart. (University of Washington, American Heart Association, Red Cross, Mayo Clinic). The American Heart Association's goal is that no one should die from heart stoppage.

Many people, young and old, have DNR orders, because they do not want CPR if their heart stops, and prefer to die without the attempt at resuscitation. Here are some of the tradeoffs:

 Sources:  2017 data outside hospitals from MyCARES, 2017  Non-Traumatic National Survival Report. 2016 data in hospitals from pages e357, e365, Heart Disease and Stroke Statistics-2018 Update. 2014 data on 64% revival in hospitals from "Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest." 2000-2009 data on change in mental problems in hospitals calculated from "Trends in Survival after In-Hospital Cardiac Arrest."

Broken Bones: An overlapping  8% to 9% of survivors have broken bones from CPR, and 91-92% do not.
Heart stoppages are rare in hospitals, one per 1,700 patient days (page e356)
We can do better:  Rates will improve as the best practices spread. Survival in hospitals is better on weekdays and in some hospitals. Survival outside is better for some ambulance services.
Mental outcomes can improve in the first 6 months after hospital discharge.
CPR survivors (whose heart stopped in a hospital) had about the same frequency of mental problems before and after CPR, based on 12,000 survivors 2000-2009:
Survivors       Survivors
before CPR    after CPR
       16%                18%         Severe Mental Problems (dependent on others)
       30%               31%         Moderate Mental Problems (can independently do activities of daily life)
       53%               50%         Mild or No Mental Problems

• As the table shows, about 2 percentage points more of survivors were dependent on others, after CPR than before, and one percentage point more had moderate problems. A rate of 3% worse off, among 26% who now survive to leave the hospital, means 1%, of all patients where CPR was tried, left hospital with worse mental problems than when they arrived.
• Definition of levels of Cerebral-Performance Category (CPC) score
• The paper does not show survivors' disability levels before CPR, but the supplement shows levels after CPR (page 13) and risk ratios for survival at each level (page 17), which allow estimates. Pre- and post-CPR data are for hospitals 2000-2009, the most recent study. Hospitals have improved CPR, so these rates are not likely to have deteriorated since 2009.

If no one sees a patient collapse outside a hospital, CPR cannot be done, so there is no difference between DNR and CPR. In a hospital, patients are closely monitored, so heart stoppages are noticed.
Organ Donation: 2015 guidelines say liver and kidneys may be donated if CPR is done, even without success, and all organs can be donated if the patient revives but dies in the hospital. Donations may still be limited by hospital abilities and patient condition.

CPR includes strong repeated pushes inward on the chest of an unconscious patient, while the patient lies on a hard surface (not on a bed), in a safe place, until the patient recovers.  As soon as a defibrillator (AED) arrives, it gives an electric shock, which can help convert some unhealthy heart rhythms to a healthy rhythm. After defibrillation the patient may still need more chest compressions, a breathing mask or tube and injections. Quick insertion of a breathing tube used to be standard, but it did not save lives or reduce brain damage. Even after recovery, the heart needs help to recover for a few days, involving many steps such as oxygen, drugs, imaging the blood vessels, and maybe cooling the body.

"Vomiting is the most frequently encountered complication of CPR. If the victim starts to vomit, turn the head to the side and try to sweep out or wipe off the vomit. Continue with CPR... Even CPR performed on strangers has an exceedingly rare risk of infection. There is NO documentation of HIV or AIDS ever being transmitted via CPR."

Most nursing homes lack defibrillators; a few have them, so your choice of nursing home affects how long CPR may take until medics arrive with a defibrillator.  Patients need to be put immediately on a bed board or the floor, since CPR on a bed does not compress the chest enough.

People often write limiting directives, such as DNR orders, on the assumption they'll come into play for old age, coma or dementia. But heart attacks may come any time, putting the directives into effect, so directives need to treated seriously.

Patients who want full care need to be ready for doctors' resistance. A Houston study said, "All physicians reported interpreting requests to 'do everything' as a 'red flag', a sign to more thoroughly explore what 'everything' meant to the patient or family." Caucasian doctors said such families "might be in denial." Hispanic and African American doctors said such requests could show suspicion of doctors.

Researchers have found that as people decline, they're comfortable with more care, just as people with disabilities are, "Patients often cannot envision being  able to cope with disability... However, once patients experience those health states, they are often more willing to accept even invasive treatments." The researchers also found that for irreversible or terminal illness, "physicians and surrogates frequently have difficulty determining when patients are in these states." These are reasons to choose a representative you trust, who knows your goals. 

Another article discusses medical representatives and directives, and you can put your instructions online for immediate access if medics look.

If you choose DNR, it needs to be signed by a doctor, and a copy of the signed DNR needs to be in your wallet or purse, as well as online, for immediate access. Emergency medics need to see a doctor's signature, in order to honor a DNR. Pittsburgh (UPMC) offers a card to print on pink cardstock and keep with you, with room for a doctor's signature.

Some people might prefer CPR, with its chances for good results, combined with an advance directive for suicide if they are among the few who develop a severe disability. Directive and suicide laws do not allow that combination. Even so, you can discuss with your medical representative and doctors whether you want your directive to say, if CPR causes severe mental deterioration, do you want "palliative sedation ... to manage intractable symptoms, maybe through reduction of consciousness or complete unconsciousness"? Directives often call for relief of pain or discomfort "even if it hastens my death". However most patients with mental deterioration turn out to enjoy their lives: the "disability paradox," where people with a severe disability are usually happy in their life, and say they have a good quality of life, so they want to continue, even in the most  severe locked-in state. Their unhappiness, if any, comes from pain, fatigue, lack of control or purpose, and isolation, which can all be minimized.

Directives reduce care long before death: 60% of US surgeons will not offer a high-risk operation to patients whose advance directives limit followup care.

20% of patients with a DNR order "wanted a trial resuscitation for cardiac arrest," which they will not get, so patients need to decide carefully about DNR. Among patients with a "Do Not Intubate" order, 58% wanted intubation in some scenarios. This 2013 study has had no follow-ups.

Patients with a Do Not Resuscitate (DNR) order die sooner, even when they are not very sick, because they are denied many treatments besides CPR, so DNR prevents fine-tuning exactly what you want and don't want. A 2016 editorial from AMA says that:

• "Other studies [7] have shown that DNR patients have higher mortality at all levels of severity of illness, which in theory should not be the case since DNR status should be relevant only in catastrophic situations." The cited study discusses survival after CPR. Even among the healthiest patients, some had a DNR order within 12 hours after CPR, and only 7% of these survived to hospital discharge. Among equally healthy patients without DNR, 70% survived.
• "patients with early orders [DNR on first day of hospital stay] receive less-aggressive treatment overall, including potentially critical interventions, such as blood transfusions, cardiac catheterizations, cardiac bypass surgery, and operations for surgical complications [4, 5]"
• "Qualitative studies might help, as might a more data-driven and patient-centered approach to DNR discussions. However, neither of these approaches is likely in the short term."

Resuscitation works well enough so your chances of leaving the hospital alive are, on average:

• 26% in 2016 if your heart stops in a hospital.  The Heart Association's goal is 38% survival by 2020  85% of these survivors "had good functional status at hospital discharge." (p.e357)
• 16% in the community, if someone sees you fall; goal was 16%
  
• 9% in a nursing home
• 12% for people over 90, or on dialysis
• 50-80%  in an operating room

Your chances are already better than this when medics and hospitals use the best practices available (rapid defibrillation, adrenaline, cooling patients, ability to catheterize, etc). The 2020 goal is based on expanding best practices. Another benefit of CPR is that over 1,000 organs per year are transplanted from patients where CPR was attempted. Although CPR did not save these patients, it did save the organs, which helped save others.

At 26% survival, hospitals need to give CPR to 4 patients to prevent one death. This is far better than other treatments. Even 9% survival in nursing homes means 11 are treated to save one, which  is better than most treatments.

Number Needed to Treat (Number of patients treated, to save one life):

• 11   CPR in nursing home, 9% average survival to hospital discharge
• 8   CPR for patients over 90, or on dialysis, 12% average survival to hospital discharge
• 7   CPR in community, 14% average survival to hospital discharge with good mental capacity
• 6   CPR in community, 16% average survival to hospital discharge, total
• 4   CPR in hospital, 25% average survival to hospital discharge with same mental capacity as admission
• 4   CPR in hospital, 26% average survival to hospital discharge, total

JAMA 2018: Most heart treatments need to treat more patients, for many years, to save a life:

• 24   ARB   CHARM-Alternative trial   angiotensin II receptor blocker
• 21   ARNI   PARADIGM-HF (vs enalapril) trial   angiotensin receptor neprilysin inhibitor
• 18   ACEI   SOLVD trial   angiotensin-converting enzyme inhibitor
• 15   MRA   EMPHASIS-HF trial   mineralocorticoid receptor antagonist
• 14   ICD   SCD-HeFT trial   implantable cardioverter defibrillator
• 14   CRT   RAFT trial   cardiac resynchronization therapy
• 11   ARNI   PARADIGM-HF (vs imputed placebo) trial   angiotensin receptor neprilysin inhibitor
• 8   β-Blocker   MERIT-HF trial  

Bandolier at Oxford (also has Number Needed to Treat for many other treatments):

• 18   ACEI   AIRE trial   angiotensin-converting enzyme inhibitor
• 14   Insulin (intensive schedule)

CPR's 9% to 26% odds also look good compared to disasters, where teams search as long as there is even a 1% chance of rescuing survivors. Or if you had cancer, would you choose a treatment with 9% or 26% odds of remission after brief treatment, over an alternative of immediate death? 

Trying CPR is cheap, $181 under Medicare. Further care costs much more, but is only done on the living, or to save organs for transplant.

Doctors' doubts about CPR success contrast with their endorsement of cancer screening, though that rarely saves lives.

Survival rates vary for different types of patients. Survival is average or better for patients with heart attacks, heart failure, stroke, or diabetes. Survival is also higher (25%) when patients are on cardiac monitors, which detect stoppages immediately.

Survival rates are below average, even in a hospital, for:

• heart stoppages at night (16% survival)
• blacks (15%)
• people in poor zip codes (13%)
• over 90 years old (12%)
• on dialysis (12%)
• patients "dependent on others for daily support because of impaired brain function," e.g. dementia (11%)
• people with cancer (10%)
• people with liver failure (10%)
• patients dependent because of brain function who live in nursing homes (9%)

As noted, the goal is to raise these rates, so they will be higher by the time you need CPR.

Ribs are broken in 8% to 9% of patients who are revived by CPR outside of hospitals:

• The rate of rib fractures was the same whether patients got CPR from bystanders or emergency responders
• "Compression-induced injuries detected via routine post-arrest care are likely to be largely insignificant in terms of length of recovery." 
• "chest compressions that enabled survival, whether delivered manually or mechanically, are rarely associated with significant morbidity."
• A discussion among emergency responders disagreed whether popping sounds they hear are cartilage loosening, or ribs cracking. One says, "having some broken ribs is a much better outcome than if you stopped cpr due to broken ribs"
• "Injuries of the upper respiratory system were not observed in our patients" [dental, lip, larynx or tracheal injuries]

Defibrillators are in many public places, but a 2004 survey found them in less than a seventh of US nursing homes (except Seattle, which has made a city-wide push for defibrillation).

• 8% in Boston nursing homes

• 11% in Philadelphia
• 13% in Omaha
• 33% in Seattle

Since that study, some states require defibrillators in senior housing, health facilities, sports facilities, schools and large businesses. If you want resuscitation and need to live in assisted housing or a nursing home, it is important to ask about their equipment and policies on using it, and you may need to buy your own.

Defibrillators can help patients whose heart starts fibrillating, and who don't have an implanted defibrillator. Automated external defibrillators (AED) have pads to stick on the patient's skin which measure the patient's heart rhythm. If it is fibrillating, the machine advises a shock which comes through the same pads. The shock stops the heart, so it can restart itself correctly. 

Ventricular fibrillation (VF) decays quickly to a stopped heart, so getting the AED and attaching it within 1-3 minutes is essential. 

However even when the heart is completely stopped (asystole), 13% survive to leave the hospital alive if it stopped in a hospital, 4% in a nursing home, and 2% in the community, because of injections and chest compressions. These figures are striking, though they don't affect decisions for or against resuscitation. The rhythm isn't known until after resuscitation starts, so people need to decide their CPR preferences based on the total survival rate.

The PulsePoint app lets 911 call citizens near a cardiac arrest who've been trained in CPR.

The Heart Association has training videos. The PulsePoint app lets 911 call citizens near a cardiac arrest who've been trained in CPR.

52-year-old Tony Gilliard from South Carolina narrates a video of his heart stoppage while playing basketball in 2013. CPR and AED brought him back. 2 minutes. youtu.be/v=YrBq_sFV3LA

62-year-old John Ellsworth's heart stopped in a British street. He needed 3 AED shocks to revive, then was taken to a hospital where they treated him, and eventually placed a defibrillator in his chest. 10 minute video narrated by the BBC series Real Rescues. youtu.be/nxpYuVr53zQ

71-year-old Nebraska lobbyist Tom Vickers collapsed in 2008 from a heart attack at the state Capitol. CPR and AED administered by a doctor on duty revived him. He was taken to a hospital, where they found 99% blockage in an artery. Video from security camera. no sound. 3 minutes.
News article: journalstar.com/news/local/quick-action-by-many-helps-lobbyist-survive-heart-attack/article_c64eb533-d5bb-5eae-99ee-54a7b12a414e.html
Video: youtube.com/watch?v=fNdDzmcwA0w

51-year-old Chris Solomons in Britain had a heart attack and felt his hands shake and his limbs tingle. He worked at a site which dispatched helicopter medics, and he was still not feeling well when he got there. The medics there took an EKG, which did not look right so they were getting ready to get him to a hospital, but he collapsed. They used CPR and 2 AED shocks to revive him, and flew him to a hospital where doctors found a blocked artery and opened it with a stent. 13 minutes. He says,

• "I’ve been able to experience so much and if it wasn't for the guys doing CPR on me and the AED they used I wouldn't be here.
• "I cannot say strongly enough how important it is that AEDs are in communities. Not in locked cupboards, but out there, placed where they are needed."

Text: heartrhythmcharity.org.uk/www/media/files/130213-sh-1-Chris_Solomons_case_study.pdf
Video: youtube.com/watch?v=w32PUDL2lb8

A man collapsed in a car, and police arrived to pull him from the car. They and a passing nurse gave CPR and AED. The wife panicked, swore, prayed, and yelled at her husband not to leave her. An ambulance arrived and took over. The man lived and left the hospital in a few days. The nurse and police were given awards for their fast action. It seems to be filmed from a camera mounted on the first police car. 4 minutes.
youtube.com/watch?v=HxlIAQj4IWY

An Augusta Georgia video shows two patients in the emergency room at the same time. Many of the comments heard on the video use abbreviated medical language. 11 minutes.

45-year-old runner who collapsed at a race got CPR immediately from other runners, and AED after 12 minutes. He was taken to the hospital and revived with cooling treatment. Revival required a breathing tube, which was removed 2 days later. 

65-year-old woman collapsed at home with husband, went several minutes without CPR. An ambulance crew got some response from her heart, using sodium bicarbonate and another medicine, but she died in the emergency room. youtube.com/watch?v=NWKyXYnvlpM

CPR saved the life of reporter Steve Lopez, and he wrote how it saved an ex-judge who collapsed while driving alone.

August 2018 guidelines say about patients in vegetative states or unresponsive wakefulness syndrome, even after 3 or 12 months:

"a substantial minority ... will recover consciousness... While most of these patients will be left with severe disability... some will regain the ability to communicate reliably, perform self-care activities, and interact socially" (p.6)

They say doctors should stop talking about permanent states and tell people the "prognosis is not universally poor," though after 3 months for non-traumatic injuries (loss of oxygen to the brain) and 12 months for accident injuries (trauma), they should emphasize "the likelihood of permanent severe disability and the need for long-term assistive care" (p.4).

The guidelines also recommend transfer to a specialized center.

In 2018 a  man was about to have his life support removed after 3 weeks in a diabetic coma, when his doctor father arranged to have him air-lifted to a specialized hospital, where he woke up in 4 days.

Videos include the following, and you can find many more. Several of these people were aware of what was happening when they were in comas. Most were not treated in specialized centers. A wise commenter said, "I hope they read to the patient." Talking books and music can fill a thirsty mind. Knowing the patient may be conscious makes everyone more helpful, considerate and respectful.

• 47 minutes: After 20 years in a nursing home in a coma caused by a car accident, Sarah Scantlin began to speak and interact. She stayed in the nursing home another 12 years until her death in 2016. After 23 days in a coma caused by a different car accident, another woman in the same video recovered much of her functions, but sees that her brain is not as smart as before. Terry Wallis, not in the video, awoke after 19 years; researchers found that his brain rewired its connections while he was minimally conscious.
• 12 minutes: After 4 years in coma caused by diseases in brain and spinal cord, Victoria Arlen recovered, dances even though unable to feel her legs, and became an ESPN presenter.
• 10 minutes: After 4 years at home in a coma caused by lack of oxygen after a heart attack, TJ Quinnell is still in a coma, while his parents move his limbs to maintain muscle tone.
• 6 minutes: After a month in a hospital in a coma caused by lack of oxygen, and even fMRI testing found his brain non-responsive, Juan Torres recovered speech and abilities, though slower and still in a wheelchair. More details are in Chapter 13, pp.207-225 of Into the Gray Zone ($2).
• 14 minutes: After a month in a hospital in a coma caused by Guillain Barre Syndrome, Terry Newbury  gradually can control his eyes, then his voice and body. Jenny Bone, with GBS, heard the hospital ask her husband about removing her ventilator. She'd always said she didn't want to be on a ventilator, but he kept her on it for more time, and she woke up in 10 days. 80% of GBS patients recover in 3 years.
• 5 minutes: After 2 weeks in a hospital in a medically induced coma, Claire Wineland describes what it was like to be in the coma.

This page gives a very brief summary of the 2018 guidelines. Families with someone in a coma need to read the guidelines, the studies they cite, and any newer studies, to find what is relevant to their situation. Most doctors and hospitals are not experts in this area, which is why the guidelines recommend transfer to a specialized setting, and why the doctor above did so for his son.

• Half of one sample achieved daytime independence at home, and 22% returned to work or school. In another sample 20% returned to work after 1 to 5 years (p.5).
• Among the few patients in one study who could not respond at all to commands by the end of rehabilitation and who had 5 years of follow-up, half could respond a year later (p.6), and three quarters could by 5 years later (p.62).
• 14% of patients with any type of coma caused by trauma, took over a year to recover consciousness; some took 3 years.
• 17% of patients whose vegetative state was not caused by trauma, and lasted at least 3 months, recover consciousness at 6 months. For those still in vegetative state at 6 months, another 7.5% to 17% recovered consciousness in different studies.
• Recovery is more likely from strokes and loss of oxygen to the brain, than from neurodegenerative disease (p.6).

People with a severe disability are usually happy in their life, and say they have a good quality of life, so they want to continue. Their unhappiness, if any, comes from pain, fatigue, lack of control or purpose, and isolation. These can usually, not always, be helped by pain specialists, good care, assistive technologies which even respond to eye movement or breaths, and social connections. People who cannot move and are locked in their bodies without motion, can still spell or speak through assistive devices, use social media, listen to books, magazines, podcasts, radio, and maybe select music from a service like Pandora or Slacker, which adjusts itself to their choices.

The "disability paradox" is that people without a disability cannot imagine how life with a disability can be fun. Family members rate quality of life much lower than a disabled person herself does.  Geriatricians say, "it is vanishingly rare that a patient reports to us a preference to be dead," no matter how badly disabled the patient is.