The annual guide to "America's best hospitals". Evidence of influence among health care leaders

The Validity of All-Cause 30-Day Readmission Rate as a Hospital Performance Metric After Primary Total Hip and Knee Arthroplasty: A Systematic Review

BACKGROUND

Risk-adjusted all-cause 30-day readmission rate (ACRR) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is currently used as a metric of hospital performance as part of the Hospital Readmissions Reduction Program. However, the extent to which it is determined by hospital-related factors and is therefore a fair method of determining reimbursement remains unclear.

METHODS

Our aim was to systematically review the available literature pertaining to whether ACRR is a valid metric of hospital performance after elective primary THA or TKA as determined by (1) its association with other performance metrics, (2) the extent to which variation in ACRR can be explained by between-hospital variation, and (3) the relative importance of hospital-related versus surgeon- or patient-related factors in determining ACRR. The MEDLINE, EMBASE, and Health Management Information Consortium databases were searched from inception to November 2018 and reference lists of selected articles scanned. The final list of articles was determined by consensus.

RESULTS

Eight articles were included. Correlation of ACRR with established composite metrics of both outcome and process measures was poor. There was a weak positive correlation between ACRR and mortality. Only 1.5% of the variation in readmission rates for THA and TKA was found to be attributable to hospital-level factors, with patient-related factors such as age and comorbidities having much greater influence. Use of composite outcome metrics, for example, combining readmission and mortality, or considering the "surgical" readmission rate, improved the sensitivity to detect important between-hospital variation.

CONCLUSION

There is insufficient evidence in the current literature to justify the use of ACRR following elective THA and TKA for financially penalizing hospitals. Further work is needed to define what is acceptable variation. The use of a composite metric or surgical readmission rate may improve the ability to detect between-hospital variation.

An Empirical Investigation of "Physician Congestion" in U.S. University Hospitals

We add a new angle to the debate on whether greater healthcare spending is associated with better outcomes, by focusing on the link between the size of the physician workforce at the ward level and healthcare results. Drawing on standard organization theories, we proposed that due to organizational limitations, the relationship between physician workforce size and medical performance is hump-shaped. Using a sample of 150 U.S. university departments across three specialties that record measures of clinical scores, as well as a rich set of covariates, we found that the relationship was indeed hump-shaped. At the two extremes, departments with an insufficient (excessive) number of physicians may gain a substantial increase in healthcare quality by the addition (dismissal) of a single physician. The marginal elasticity of healthcare quality with respect to the number of physicians, although positive and significant, was much smaller than the marginal contribution of other factors. Moreover, research quality conducted at the ward level was shown to be an important moderator. Our results suggest that studying the relationship between the number of physicians per bed and the quality of healthcare at an aggregate level may lead to bias. Framing the problem at the ward-level may facilitate a better allocation of physicians.

From Research to Practice: Which Research Strategy Contributes More to Clinical Excellence? Comparing High-Volume versus High-Quality Biomedical Research

The question when and to what extent academic research can benefit society is of great interest to policy-makers and the academic community. Physicians in university hospitals represent a highly relevant test-group for studying the link between research and practice because they engage in biomedical academic research while also providing medical care of measurable quality. Physicians' research contribution to medical practice can be driven by either high-volume or high-quality research productivity, as often pursuing one productivity strategy excludes the other. To empirically examine the differential contribution to medical practice of the two strategies, we collected secondary data on departments across three specializations (Cardiology, Oncology and Orthopedics) in 50 U.S.-based university hospitals served by 4,330 physicians. Data on volume and quality of biomedical research at each department was correlated with publicly available ratings of departments' quality of care, demonstrating that high-quality research has significantly greater contribution to quality of care than high-volume research.

Rankings versus reality in pancreatic cancer surgery: a real-world comparison

BACKGROUND

Patients are increasingly confronted with systems for rating hospitals. However, the correlations between publicized ratings and actual outcomes after pancreatectomy are unknown.

METHODS

The Massachusetts Division of Health Care Finance and Policy Hospital Inpatient Discharge Database was queried to identify pancreatic cancer resections carried out during 2005-2009. Hospitals performing fewer than 10 pancreatic resections in the 5-year period were excluded. Primary outcomes included mortality, complications, median length of stay (LoS) and a composite outcomes score (COS) combining primary outcomes. Ranks were determined and compared for: (i) volume, and (ii) ratings identified from consumer-directed hospital ratings including the US News & World Report (USN), Consumer Reports, Healthgrades and Hospital Compare. An inter-rater reliability analysis was performed and correlation coefficients (r) between outcomes and ratings, and between rating systems were calculated.

RESULTS

Eleven hospitals in which a total of 804 pancreatectomies were conducted were identified. Surgical volume correlated with overall outcome, but was not the strongest indicator. The highest correlation referred to that between USN rank and overall outcome. Mortality was most strongly correlated with Healthgrades ratings (r = 0.50); however, Healthgrades ratings demonstrated poorer correlations with all other outcomes. Consumer Reports ratings showed inverse correlations.

CONCLUSIONS

The plethora of publicly available hospital ratings systems demonstrates heterogeneity. Volume remains a good but imperfect indicator of surgical outcomes. Further systematic investigation into which measures predict quality outcomes in pancreatic cancer surgery will benefit both patients and providers.

[Development and validation of a questionnaire to measure hospitals' social reputation]

OBJECTIVE

To design and validate a questionnaire (MeFio) to measure the social reputation of a hospital from patients' and citizens' perspective.

MATERIAL AND METHODS

We performed a literature review to define the concept of a hospital's social reputation. Four nominal groups were conducted to set up the a priori factors of the MeFio questionnaire. These groups consisted of 47 managers and health professionals and 32 potential customers. Reactive items were identified and a pilot test was conducted to examine comprehension. A random sample of 385 subjects was selected. Ceiling and floor effects, internal consistency, reliability, and construct and criteria validity were analyzed.

RESULTS

A total of 343 validated questionnaires (response rate 89%) were collected. The MeFio questionnaire has 21 items grouped into five factors. All items had an item-total correlation higher than 0.30. All factor loads were higher than 0.5; between 66.2% and 80.4% of the variance was explained and Cronbach's alpha was 0.7- 0.88. The construct-composite-reliability scores were higher than 0.7. Standardized scores in the convergent discriminant validity test were higher than 0.6. The factors explained 50% of the variability in satisfaction with the health care received (F = 66.5; p <0.001).

CONCLUSION

The MeFio questionnaire is a valid and reliable tool to measure the five dimensions that define the reputation of a hospital in Spain.

Total knee arthroplasty outcomes in top-ranked and non-top-ranked orthopedic hospitals: an analysis of Medicare administrative data

OBJECTIVE

To examine outcomes of Medicare enrollees who underwent primary total knee arthroplasty (TKA) in top-ranked orthopedic hospitals identified through the U.S. News & World Report hospital rankings and 2 comparison groups of hospitals.

PATIENTS AND METHODS

We used Medicare Part A data to identify patients who underwent primary TKA between January 1, 2006, and December 31, 2006, in 3 groups of hospitals: (1) top-ranked according to U.S. News & World Report rankings; (2) not top-ranked, but eligible for ranking; and (3) not eligible for ranking by U.S. News & World Report. We compared the demographics and comorbidity of patients treated in the 3 hospital groups. We examined rates of postoperative adverse outcomes--a composite consisting of hemorrhage, pulmonary embolism, deep vein thrombosis, wound infection, myocardial infarction, or mortality within 30 days of surgery. We also compared 30-day all-cause readmission rates and hospital length of stay (LOS) across groups.

RESULTS

Our cohort consisted of 48 top-ranked hospitals (performing 10,477 primary TKAs), 288 eligible non-top-ranked hospitals (28,938 TKAs), and 481 hospitals not eligible for ranking (25,297 TKAs). Unadjusted rates of the composite outcome were modestly higher for top-ranked hospitals (4.3%, 455 patients) as compared with non-top-ranked hospitals (4.1%, 1191 patients) and hospitals ineligible for ranking (3.3%, 843 patients) (P<.001), but these differences were no longer significant after accounting for differences in patient complexity. Likewise, there were no significant differences in readmission rates or LOS across groups.

CONCLUSION

Rates of postoperative complications and readmission and hospital LOS were similar for Medicare patients who underwent primary TKA in top-ranked and non-top-ranked hospitals.

Role of reputation in top pediatric specialties rankings

OBJECTIVE

Although the role of reputation in determining the relative standings in the U.S. News & World Report (USNWR) annual rankings of the top 50 hospitals has received analytical attention, the role of reputation in the best children's hospitals pediatric specialty rankings has not been quantified. Our goal was to quantify the role of reputation in determining the relative standings of the top-ranked pediatric specialties and their associated hospitals in the 2008-2010 editions of the USNWR best children's hospital rankings.

METHODS

A cross-sectional study of USNWR data collected from the top 30 hospitals in each of 6 (and later 10) specialties was performed. The main outcome measures were rankings based on total USNWR scores and subjective reputation scores.

RESULTS

On average, rankings based on reputation scores alone correlated with USNWR overall rankings; correlation coefficients ranged from 0.80 to 0.98 (Spearman Correlation; mean P < .001). This relationship was consistent over all 3 survey years.

CONCLUSIONS

The relative standings of the top 30 pediatric hospitals in each of 10 specialties are largely explained by the compelling correlation between subjective reputation scores and ranking scores.

U.S. News and World Report's rankings of the top 50 children's hospitals for diabetes and endocrinology reflect reputation more than objective measures

The objective of this short communication was to evaluate the roles of reputation and objective measures in U.S. News rankings of the top 50 children's hospitals for diabetes and endocrinology. Analysis was performed on data obtained from the 2011 to 2012 report. Reputation scores exhibited more variance (CV = 158%) compared to objective measures (average CV = 14%). Ranking hospitals based on reputation, compared to total score, identified the same top hospital, same top five hospitals, and 90% of the same top 10 hospitals. Ranking based on total objective score resulted in different top hospitals, 60% of the same top five hospitals, and 50% of the same top 10 hospitals. Hospital total rank was strongly associated with reputation rank (rho2 = 0.78) and moderately associated with objective rank (rho2 = 0.48). Objective rank was minimally associated with reputation rank (rho2 = 0.19). Among the top 50 children's hospitals in diabetes and endocrinology, standings reflect reputation more than objective measures.

Inadequate website disclosure of surgical outcome of intracranial aneurysms

Social demand for the disclosure of medical information is increasing, especially the treatment for unruptured intracranial aneurysms. This study investigated to what extent information on the treatment for unruptured intracranial aneurysms is disclosed on websites in Japan. We surveyed 1225 institutions authorized by The Japan Neurosurgical Society. The following factors were analyzed: percentage of institutions with websites, disclosure of number of surgeries, and disclosure of outcome of treatment for ruptured and unruptured intracranial aneurysms. Of the 1225 institutions surveyed, 1097 (89.6%) had their own websites. The total number of websites was 1262 since some institutions have several homepages in different websites. The annual number of surgeries was shown in 274 of the 1225 institutions (22.4%). The outcome of treatment for ruptured intracranial aneurysms was disclosed in 104 of the 1225 institutions (8.5%). The outcome of treatment for unruptured intracranial aneurysms was shown in only 32 of the 1225 institutions (2.6%). Disclosure of outcome of treatment for unruptured intracranial aneurysms on websites is not common. To improve disclosure of the outcome on websites, guidelines should be established.

Do the leading children's hospitals have quality web sites? A description of children's hospital web sites

Background

Although leading children's hospitals are recognized as preeminent in the provision of health care to children, the quality of their Web sites has not been described.

Objective

To describe technical characteristics of the Web sites of leading children's hospitals.

Methods

This is a cross-sectional descriptive infodemiology study. Two reviewers independently reviewed and analyzed the Web sites of 26 nationally prominent children's hospitals in June 2003, using objective criteria based on accessibility (based on age and language), attribution, completeness, credibility, currency, disclosure, readability, and other technical elements.

Results

One-third of Web sites included content for children and adolescents. Twenty-four (92%) of the Web sites had health and disease-specific information. One-third contained only English, while two-thirds included other languages. All 26 Web sites included a disclaimer, although none had a requirement to read the disclaimer before accessing health and disease specific information. Twenty-four (92%) had search options. Although most (85%) listed a copyright date, only 10% listed the date last updated.

Conclusions

This is the first study to examine the Web sites of leading children's hospitals. Although the Web sites were designed for children's hospitals, only a few sites included content for children and adolescents. Primary care physicians who refer patients to these sites should be aware that many have limited content for children, and should assess them for other limitations, such as inconsistent documentation of disclaimers or failure to show the date of the last Web site update. These Web sites are a potentially useful source of patient information. However, as the public increasingly looks to the Internet for health information, children's hospitals need to keep up with increasingly high standards and demands of health-care consumers.

Do "America's Best Hospitals" perform better for acute myocardial infarction?

BACKGROUND

"America's Best Hospitals," an influential list published annually by U.S. News and World Report, assesses the quality of hospitals. It is not known whether patients admitted to hospitals ranked at the top in cardiology have lower short-term mortality from acute myocardial infarction than those admitted to other hospitals or whether differences in mortality are explained by differential use of recommended therapies.

METHODS

Using data from the Cooperative Cardiovascular Project on 149,177 elderly Medicare beneficiaries with acute myocardial infarction in 1994 or 1995, we examined the care and outcomes of patients admitted to three types of hospitals: those ranked high in cardiology (top-ranked hospitals); hospitals not in the top rank that had on-site facilities for cardiac catheterization, coronary angioplasty, and bypass surgery (similarly equipped hospitals); and the remaining hospitals (non-similarly equipped hospitals). We compared 30-day mortality; the rates of use of aspirin, beta-blockers, and reperfusion; and the relation of differences in rates of therapy to short-term mortality.

RESULTS

Admission to a top-ranked hospital was associated with lower adjusted 30-day mortality (odds ratio, 0.87; 95 percent confidence interval, 0.76 to 1.00; P=0.05 for top-ranked hospitals vs. the others). Among patients without contraindications to therapy, top-ranked hospitals had significantly higher rates of use of aspirin (96.2 percent, as compared with 88.6 percent for similarly equipped hospitals and 83.4 percent for non-similarly equipped hospitals; P<0.01) and beta-blockers (75.0 percent vs. 61.8 percent and 58.7 percent, P<0.01), but lower rates of reperfusion therapy (61.0 percent vs. 70.7 percent and 65.6 percent, P=0.03). The survival advantage associated with admission to top-ranked hospitals was less strong after we adjusted for factors including the use of aspirin and beta-blockers (odds ratio, 0.94; 95 percent confidence interval, 0.82 to 1.08; P=0.38).

CONCLUSIONS

Admission to a hospital ranked high on the list of "America's Best Hospitals" was associated with lower 30-day mortality among elderly patients with acute myocardial infarction. A substantial portion of the survival advantage may be associated with these hospitals' higher rates of use of aspirin and beta-blocker therapy.

What patients should ask of consumers' guides to health care quality

Consumers' guides that profile the quality of care of individual health care providers may be influential in shaping health care markets. We propose four simple questions that can be used to evaluate such guides: (a) Does the guide measure distinct and important domains of health care quality? (b) Are the individual measures of quality described simply and precisely? (c) Do the measures take into account relevant differences between patients? (d) Are the ratings of quality presented fairly? Using these four questions, we examine the validity of one prominent guide that annually identifies America's best hospitals and present a set of recommendations for the design of future guides. Although the evaluation of health care quality is undoubtedly complex, the four questions that we pose provide a basis for developing a more rational approach to informing the public about health care quality.