U.S. News's 'Best Hospitals' Clashes With Other Ratings. Is That Bad?
http://tinyurl.com/5zfwne
November 14, 2008 04:05 PM ET
U.S. News, publisher of the annual "Americas Best Hospitals" rankings,
isn't the only hospital-rating game in town. Cor****ate-backed groups
such as Leapfrog and the federal government's Medicare arm, through its
Hospital Compare page on the Web, are other examples of public re****ting
of hospital data and ratings, each with its own unique approach. A new
study in Health Affairs , a public-policy journal, concludes that
because the ratings measure different qualities and disagree with one
another, consumers are confused rather than enlightened. As Health
Affairs puts it, sometimes more is less.
I see the point, but I think motivated consumers—as I would call anyone
looking for information about particular hospitals—can sort things out
better and be smarter than the authors seem to believe they can. And the
pot of gold the authors are seeking at rainbow's end—broad-based
information that is useful, accurate, and consistent across different
re****ting platforms—is wishful, almost delusional thinking. Developing a
consensus among clinicians, analysts of data quality, and occupants of
hospital executive suites about how to define, collect, measure, and
re****t data that is meaningful is far more difficult than herding cats
or whatever comparison you want to make.
Hospital Compare is a good example. After years of wrangling, hospitals
finally agreed on a set of "process measures" that the Centers for
Medicare and Medicaid Services could make public. The roughly dozen
measures would show how consistently heart attack patients received an
aspirin after they got to the ER, how often surgical antibiotics were
administered at the appropriate times, whether heart patients who smoked
were counseled to stop smoking, and other such checklist-type
compliance. The majority of the measures relied on evidence ac***ulated
over many years. They made sense.
But how well do they predict whether patients will live or die, or
suffer complications? Several studies have shown that a center's
performance on Hospital Compare process measures has little to do with
outcomes, such as the mortality rate of heart patients who have bypass
surgery. A 2007 study in the Journal of the American Medical Association
found that one of the measures, whether heart failure patients got drugs
called ACE inhibitors or ARBs when they were sent home, had little
effect on the death rate during the following two to three months.
The Health Affairs study examined the results of five online providers
of comparative hospital information—U.S. News, Leapfrog, HealthGrades,
Hospital Compare, and a state-sponsored service, Massachusetts
Healthcare Quality and Cost. The authors (Michael Rothberg of the Tufts
University School of Medicine and others) checked each ratings provider
for its verdict on how well nine medium-to-large hospitals within 30
miles of Boston did with patients who had certain procedures, such as
heart bypass surgery, or had medical conditions such as
community-acquired pneumonia. Each hospital's care of heart-attack
patients also was evaluated.
The results of the analysis were predictable. Only two of the ratings
providers broke out death rates for every patient, and only three
furnished heart-attack death rates. Virtually no ratings were consistent
across all five.
But wasn't that mostly because the intent of each ratings provider is
different? And is a range of missions a bad thing? The stated purpose of
the Best Hospitals rankings, for example, is to help direct patients to
centers that excel in the most difficult cases. We are not trying to
identify hospitals that would be good choices for routine care or a
specific kind of everyday surgery. The assumption, moreover, is that
such patients, given their needs, probably are far more willing to go
some distance to meet them than most people would be. The study's
authors, by explicit contrast, state that the 30-mile radius was based
on consumers "who would be willing to travel up to one hour to receive
high-quality care." If an elderly parent needed major surgery, I suspect
that most children would be willing to go more than an hour away if they
thought their parent would get top-flight care. HealthGrades, which
focuses on specific conditions and procedures typical of large numbers
of patients, comes closer to the authors' model.
Individual patients have individual needs. If I had a history of heart
attack, you bet I'd be curious about how well my local hospital handles
emergency cases. Hospital Compare, here I come. If the issue was a hip
replacement in a low-risk patient, I might look at HealthGrades or
Leapfrog.
It is true that not many people make decisions about hospitals based on
ratings or rankings. Only about 20 percent of the public even saw such
information in the past year, according to a survey released last month
by the Kaiser Family Foundation, and of those who did, only about one
third factored it into their health decisions. The numbers were higher
for those with more education, but not dramatically. Just 6 percent of
those surveyed were aware of the Hospital Compare site.
Confusion is not the issue. If public-health authorities and the
healthcare community are committed to data transparency, the greater
challenge is to address the 80 percent of the population that doesn't
know there are data out there to be had. I smell a whiff of
condescension in the Health Affairs study (consumers, poor lambs—so
easily led astray).
I invite Dr. Rothberg to respond.
"Americas Best Hospitals"
http://health.usnews.com/sections/health/best-hospitals
Hospital Compare
http://www.hospitalcompare.hhs.gov/
Leapfrog
http://www.leapfroggroup.org/cp
HealthGrades
http://www.healthgrades.com/
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Civis Romanus Sum
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