Rewarding Medicine: Can Hospital Rankings Work for You?
Hollywood hosts awards seasons. Sports leagues present championship games and medal ceremonies. Game shows tell contestants what they’ve just won (Why is it always a jet ski? Have they been over manufactured? A question, perhaps, for a separate blog post?).
In the world of healthcare, there’s the US News & World’s annual lists of Best Hospitals. Every year, the publication ranks hospitals in fifteen specialties and seventeen procedures and conditions, as well as by region, and includes an overall tally for the top twenty. Hospitals love to boast about their rankings [Disclaimer — or humblebrag, depending on your perspective — Columbia is in the top ten], but how meaningful are these distinctions? Let’s take a deep dive into the actual value in these lists.
WHY RANK HOSPITALS?
The purpose of ranking hospitals, nationally, is two-fold.
First, these lists are intended to assist people in finding reputable and quality medical care. They serve as a kind of stamp of approval, determined by analyzing data, weighing expert opinions, patient outcomes and feedback, and confirming the presence of various agreed-upon standards within the medical community.
Second, for the hospitals being ranked, a system of rating and ranking can be an incentive to improve key quality-controls. It can shine light on best practices and ultimately lead to better care. By the same token, ineligibility for consideration may implicitly remind some hospitals of their need to step things up.
In medicine nothing is one-size-fits-all. So US News has attempted to create categories that satisfy different needs. The categories for the lists are:
- Hospitals Overall — an overall top twenty “Honor Roll” of American hospitals that score highly in a combination of the below sub-categories
- Hospitals By Region (state, and major metropolitan area) — a list of highly-rated hospitals within each state and major metropolitan area. This may be more useful information for many people, as the need for travelling cross-country should not be a barrier to good health care
- Hospitals By Specialty — a numerical ranking of hospitals, specifically based on individual departments that specialize in common and important areas of medicine. Fifteen areas have been pre-determined for evaluation:
- Cardiology & heart surgery
- Diabetes & endocrinology
- Ear, nose & throat
- Gastroenterology & GI surgery
- Neurology & neurosurgery
- Pulmonology & lung surgery
- Hospitals by Procedures and Conditions — a list of hospitals evaluated on their track records with 17 common conditions and procedures:
- Abdominal aortic aneurysm repair
- Aortic valve surgery
- Back surgery (spinal fusion)
- Chronic obstructive pulmonary disease (aka COPD)
- Colon cancer surgery
- Congestive heart failure
- Heart attack
- Heart bypass surgery
- Hip fracture
- Hip replacement
- Kidney failure
- Knee replacement
- Lung cancer surgery
- Transcatheter aortic valve replacement (aka TAVR)
- Children’s Hospitals — a list of regional hospitals with at least one highly-rated pediatric specialty (The Best Children's Hospitals “Honor Roll” recognizes 10 hospitals that are unusually competent not just in one or two specialties but in many.) For Children’s Hospitals, US News looked at these specialties:
- Cardiology and heart surgery
- Diabetes and endocrinology
- Gastroenterology and gastrointestinal surgery
- Neurology and neurosurgery
- Pulmonology and lung surgery
The process of evaluation begins with a pool of nearly 5,000 U.S. hospitals. Some of these are immediately ruled out of consideration for basic poor standards. The number is then winnowed down by various criteria, and ultimately divided up into ranked lists for each category.
For “specialties” and “procedures and conditions” rankings, where hard data can be compiled, US News looked at hospitals that satisfied any of the following four criteria:
- It was a teaching hospital.
- It was affiliated with a medical school.
- It had at least 200 beds set up and staffed.
- It had at least 100 beds and offers at least four out of eight advanced technologies associated with high-quality care, such as a PET/CT scanner and certain precision radiation therapies.
This year, 2,295 hospitals, just over half of the total number in the initial pool, met one of the four standards.
In the three specialty fields — Ophthalmology, Psychiatry, and Rheumatology — ranking is based on expert opinion surveys, and any hospital with enough nominations was eligible to be listed.
A key takeaway? If a hospital was eligible to be considered for specialty ranking, at all, it is a good sign:
Remember, even if a hospital isn’t in the top 10 or high performing, it’s one of the best hospitals in the country for that specialty by virtue of being rated at all. Our strict eligibility criteria ensure we’re only evaluating hospitals that regularly treat complex cases and therefore have the experience to provide high-quality care.
DIGGING DEEPER INTO EACH CATEGORY
TOP 20 HOSPITALS OVERALL aka “The Honor Roll”
The so-called Honor Roll of the top 20 highest rated hospitals in the U.S. is one of those “best-of-the-best” rankings, calculated from scores on sub-categories like “specialties” and “procedures and conditions.”
Hospitals were awarded Honor Roll points if they ranked in one or more of the 15 specialties that U.S. News evaluates – more points for higher rankings – and if they were rated "high performing" in one or more of the 17 procedures and conditions. The 20 hospitals with the highest point totals define the Honor Roll.
While this may be a prestigious-sounding recognition, it may not actually be as useful as you might think. For example, if someone needs the kind of treatment in which that particular hospital does not excel, they’d be better off going to a hospital ranked on the appropriate Specialty list, even if it didn’t make the overall Honor Roll.
HOSPITALS BY REGION
Just because a hospital is not nationally ranked, it may still receive a high-rating, and offer quality care. A “Best Regional Hospital” designation is highly relevant for those who live far from a nationally ranked hospital.
In addition to offering the public a resource for finding local care, these regional rankings also offer a second public good by revealing an unfortunate need for improvement:
In 2021-22, 531 hospitals were recognized as Best Regional Hospitals, [a decrease from 563 last year]. One state, Wyoming, had no Best Regional Hospitals.
HOSPITALS BY SPECIALTY
For each of 15 specialty areas of care, the top-performing 50 hospitals are ranked.
In 12 of the specialty areas, rankings are derived from data sources, such as Medicare: cancer; cardiology & heart surgery; diabetes & endocrinology; ear, nose & throat; gastroenterology & GI surgery; geriatrics; gynecology; neurology & neurosurgery; orthopedics; pulmonology & lung surgery; rehabilitation; and urology.
In the remaining three specialties – ophthalmology, psychiatry and rheumatology – ranking is determined entirely by expert opinion, based on responses from three years of surveys of physician specialists who were asked to name the hospitals to which they would be inclined to refer their sickest patients.”
Beyond the top 50, all other hospitals scoring in the top 10% receive a “high performing” mention (which then joins the calculations to determine the regional bests).
The “Hospitals by Specialty” category exists because hospitals may perform quite inconsistently between departments. A hospital that excels in one area of medicine may underperform in another. And vice versa. So, a hospital’s general reputation alone cannot always help guide someone toward specialized help.
Moreover, many very complex cases require true expertise. In a perfect world, hospitals lacking appropriate resources or expertise would decline performing any treatment that is beyond the capabilities of its staff...
Most hospitals would reject [a patient in their 80s or 90s with pancreatic cancer] – as indeed they should if their surgeons lack the expertise to remove the cancer without harming the rest of the fragile pancreas.
But multiple investigations by U.S. News have found that some hospitals without the requisite skills would go ahead, possibly at considerable risk. This patient would be better served by one of the hospitals in the Best Hospitals cancer rankings, many of which see a steady stream of similarly complex patients.
In other words, this list is useful for seeking treatment when it comes to some of the most difficult cases — not only to find the best care, but also to avoid the worst.
HOSPITALS BY PROCEDURES AND CONDITIONS
If ranking by specialty area wasn’t, well specific, enough…
The Best Hospitals procedure and condition ratings focus on specific and more commonly required individual procedures and conditions, such as hip replacement and heart failure, rather than on broader specialties like orthopedics and cardiology. The goal is to evaluate how well hospitals perform in each procedure or condition – and not just with the most difficult cases, as with the specialty rankings, but with the full range of patients.
An important fact about this evaluation — and an attempt to keep the metrics somewhat symmetrical — is that the rankings looked at patients who were age 65 or older to determine the success of these hospitals. As US News explains:
Older patients are at greater risk – they tend to have higher incidence and severity of comorbidities upon admission and illnesses that are more advanced than those of younger patients. The quality of care of over-65 patients is generally regarded as indicative of a hospital’s capabilities.
The takeaway? Any hospital should be able to treat such relatively common ailments successfully, and many do – but some treat them better than others.
Many would agree that children deserve and require a designated list of best hospitals. This is particularly true when, for example, rare conditions affect newborns or toddlers. It is unwise to expect the same level of pediatric medical expertise to exist in every hospital. US News says:
The 50 best-performing hospitals are ranked in each of 10 pediatric specialties... The Best Children's Hospitals Honor Roll recognizes the 10 hospitals that received the highest number of points, based on the number of specialties in which they are ranked and how high they ranked in each one.
RANKINGS & RATINGS: WHO KEEPS SCORE?
So, what makes one hospital a better performer than another? Is it like a sport, where it’s obvious who scores more points, or is it like the Oscars where personal opinion comes into play, and Merryl Streep automatically gets nominated (and rightly so)? Actually, it’s a little of both.
As mentioned earlier, each category requires a unique set of assessments, but US News offers the following breakdown, which provides an accurate overview:
- Patient Outcomes (37.5%). A hospital's success at keeping patients alive accounted for 30% of its score and was judged by comparing the number of Medicare inpatients with certain conditions who died within 30 days of admission in 2017, 2018 and 2019 with the number who would be expected to die given the severity of illness.
Hospitals were scored from 1 to 5, with 5 indicating the highest statistical likelihood that survival rate was better than expected, and 1 indicating the highest likelihood that it was worse than expected. U.S. News' calculation of each hospital's expected deaths factored in the age and sex of each patient; what kind of care he or she needed; what other illnesses (known as comorbidities) were present; whether he or she received Medicaid benefits (which is a measure of socioeconomic status); and other risk factors known to influence patients' outcomes.
- Patient experience (5%). This score reflects the percentage of patients who responded positively to a survey about the overall quality of their hospital stay known as the Hospital Consumer Assessment of Healthcare Providers and Systems. Most hospitals are required to assess patients' satisfaction using the HCAHPS survey.
- Other care-related indicators (30%). These include nurse staffing, patient volume, certain clinically proven technologies and professional and specialty-specific recognition. The 2019 American Hospital Association Annual Survey was the primary source.
- Expert opinion (27.5%). Each year, board-certified physicians in the relevant specialties are invited to list up to five hospitals, ignoring location and cost, that they consider to be the best in their area of expertise for complex or difficult cases.
AN EVER-EVOLVING POINTS SYSTEM
Medicine is always evolving: advances are discovered, problems are revealed, lessons are learned, and yes, mistakes are made. As a result the types of metrics we evaluate say a lot about what is valued. It also can determine the direction and rate of progress. As they say, what gets measured gets managed.
For this reason, US News attempts to solicit and incorporate feedback on which indicators might deserve a place in the calculations. Some interesting examples that are not yet fully integrated into the results, but seem likely to influence future rankings are :
- Equity — In the face of widespread and persistent disparities affecting the health of historically underserved populations, U.S. News believes equity is an important objective for all health care providers to pursue.
- Transparency — A measure of public transparency is incorporated into three of this year’s ratings – heart attack, heart failure and stroke – based on each hospital’s public reporting status in relevant clinical registries.
- Overuse — Overtreatment and low-value care may cost more than $100 billion per year. In the new back surgery (spinal fusion) rating, we incorporate a measure of overuse that was calculated for U.S. News by data scientists at the Lown Institute, a nonpartisan think tank... Because a pattern of overuse or low-value care is not compatible with being a high-quality provider, U.S. News will explore additional opportunities to incorporate measures of value in future editions of Best Hospitals.
WHY (OR WHEN) SHOULD YOU CARE?
Unless you’re in some betting-on-hospitals-lists group — like a very esoteric Oscars pool? — you probably want to use these lists to find quality medical care for you and your loved ones. So which one should you consult, if any? Well, it depends.
Let’s say you are...
- ...seeking treating for an especially challenging diagnosis.
You might consider using the list of “Best Hospitals by Specialty,” and finding one that excels in the area of care you need (remember to look at the top 10%, not just the top 50 hospitals)
- ...scheduling a common procedure.
Perhaps you can cross-reference your hospital of choice with the “Hospitals by Procedure and Condition” to see how it was rated on that
- ...looking for a reliable hospital in your area.
Try the “Best Hospitals by Region” list.
- ...seeking help on behalf of someone with a life-threatening or a very uncommon condition.
It might be worth considering reaching out to one of the “Honor Roll” top-twenty Best Hospitals (or Best Children’s Hospitals, if it is for a child).
Whatever the case, try to balance all this information with things like doctor’s referrals, trusted word of mouth, and good old common sense. US News states:
Patients still have to do their own research and talk with their doctors. We also understand that families have to consider such factors as the stress and expense of travel and lodging in another city and theirinsurer's willingness to pay for care if a hospital is out of network.
If you are curious to know more about the rankings, check out their answers to frequently-asked questions. Fair warning: the nitty-gritty details can form a bit of a rabbit hole. Sometimes too much information is what the kids call T.M.I. (too much information).
If anything, it might make a person realize why something like a “Best Of” list is attractive, in the first place: if every single person had to go through all the data, for each category, for each hospital, in each region...they might soon need a doctor.
Links for Further Reading
- US News – “FAQ: How and Why we Rank and Rate Hospitals”
- Boston Magazine – “Do Hospital Rankings Really Matter?”
- US News – New York-Presbyterian Hospital-Columbia and Cornell 2021-2022 Rankings