Media-driven quality rankings leave out top-performing hospitals
U.S. News & World Report and HealthGrades surveys that rank “Best Hospitals” according to their high-quality cardiovascular care do not create the most comprehensive list and may create confusion by excluding hospitals that provide the same quality of care, according to a study published in the January issue of the Journal of the American College of Surgeons.

Lead author Nicholas H. Osborne, MS, told Cardiovascular Business News that while these quality rankings do identify some of the top hospitals in the U.S., they create a “disservice” to patients by discouraging patients from receiving care at equivalent hospitals closer to home. Better quality measurements that create more comprehensive results must be developed to aid informed patient decision making, he suggested.

Osborne, a Robert Wood Johnson clinical scholar at the University of Michigan in Ann Arbor, and colleagues compared mortality rates at hospitals ranked “Best Hospitals” by U.S. News  and HealthGrades with all other facilities in the U.S., based on 2005 and 2006 Medicare data of patients who underwent some form of surgery (abdominal aortic aneurysm repair, CABG, aortic valve repair and mitral valve repair).

While Osborne said that the surveys are used as a measure of hospital quality in the media and are frequently cited in hospital marketing, “there is no peer review of their methodology and little validation that these quality ratings are actually true.”

While Osborne and colleagues found mortality rates for abdominal aortic aneurysm repair to be significantly lower in U.S. News' “Best Hospitals” survey, mortality rates for all four of the aforementioned procedures was lower in HealthGrades’ “Best Hospitals.” After the researchers controlled for hospital volume, they found that mortality rates were no different in the U.S. News top list for any of the four procedures, while patients who underwent CABG and aortic valve repair had a lower mortality rate at Healthgrades “Best Hospitals.”

It appeared that hospital volume mediated a significant proportion of the differences observed in mortality between “Best Hospitals” and all other U.S. hospitals, accounting for between 14 percent and 79 percent of the differences.

The study also showed that both surveys, which measured America’s top hospitals, rank different hospitals as the “Best Hospitals.” Only eight hospitals were ranked in both the top 50 of U.S. News' “America’s Best Cardiovascular Hospitals” and HealthGrades’ “Best Hospital" rankings.

Osborne said that this stemmed from the surveys’ differentiations in methodologies and metric systems. HealthGrades’ survey is based on risk-adjusted mortality rates within facilities, where as U.S. News is comprised of data based on three factors: medical and surgical mortality rates among Medicare beneficiaries, hospital infrastructure and peer ratings among specialists within the field.

This peer reputation in U.S. News, said Osborne, “may bias their ratings to favor large academic centers.”

“We need to do a better job of developing measures of hospital and surgical quality that not only take into account mortality but other outcomes,” said Osborne. To amend the situation, he offered that stakeholders, including hospitals, insurance carriers and third parties, must work together to develop more evidence-based systems to evaluate and measure hospital quality.

Osborne suggested that the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) may offer not only robust quality data, but a platform for improvement. The registry, administered by the ACS, collects data on procedures that take place in hospitals. Data and scores are then fed back to hospitals as a means of quality measurement. In addition, some regional collaboratives, such as the Michigan Surgical Quality Collaborative, have “demonstrated the tremendous power of collaboration, allowing hospitals to discuss their quality, and benchmark off each other and learn how to improve quality,” explained Osborne.

“This study raises an important point,” he said. “Patients are going to get mixed messages about where to go for the best surgical care. I think our study shows that overall the hospitals that are in these top ratings do have good outcomes, but they miss a lot of other hospitals with equivalent quality.”

Osborne and colleagues found that the “study has important implications for patients trying to choose safe hospitals for cardiovascular procedures” and that “patients can benefit equally from going to similarly high-volume hospitals closer to their home.”

In addition to these findings, the study also showed that patients who were treated in the “best hospitals” were of a different demographic than those treated in the unranked hospitals. Within the U.S. News report, 8.4 percent of those patients treated were African-Americans, compared to 5 percent in all other facilities. Results also showed that within U.S. News, "Best Hospitals” were less likely to operate emergently compared to the others, 55.2 percent and 52.1 percent, respectively.

“These ratings should not be developed as a simple marketing tool for hospitals. It really should be based on a system for informed patient decision making,” Osborne said. “It’s important to give patients options that are close to home or that are more convenient for them.”

“The optimal quality measurement platform has not been identified, but the more that we are working together, the closer we are going to get to a better measure of quality,” he concluded.