The spotlight on hospital-caused patient harm has become a bit brighter with the launch of Consumer Reports' hospital safety ratings, which uses several different measures than the Leapfrog Group's recent and controversial hospital letter grades, and reaches opposite conclusions about many facilities.
The CU rating system, featured in the magazine's August issue, rates hospitals in six categories:
- Infections
- 30-day readmissions
- Overuse of scanning
- Communication about new medications and discharge process (as measured by HCAHPS – the Hospital Consumer Assessment of Healthcare Providers and Systems survey)
- Patient complications
- 30-day post-discharge mortality
In addition to informing consumers, the CU rating system is aimed at hospital CEOs and boards, "in terms of their accountability," and getting them to understand they can do better, John Santa, MD, director of Consumer Reports Health Ratings Center, explained in an interview with HealthLeaders.
"We see hospitals are figuring this out, but most of them haven't. The hospitals that have are those with CEOs and boards that have decided, 'enough of this ambiguity about safety. We've had 12 years since the Institute of Medicine report To Err Is Human. This is embarrassing. And we're not going to be embarrassed by it any longer."
The magazine rates 1,159 hospitals in 44 states, fewer than half of those covered by the Leapfrog Group, which released its own 26-measure hospital safety score June 5, ranking 2,651 hospitals much like a report card from A, B, C, D or F.
CR excluded more hospitals, such as specialty and children's hospitals, federal hospitals, hospitals it determined had outdated or insufficient data, contained discrepancies, or which didn't report data in a way that CR could use.
The scores are displayed with what the advocacy group calls its traditional "fractional blob scale," or circles on a grid in which the circle may be partially or completely filled in with red or black, with a column showing each hospital's total numerical score.
And rather than A through F, the CR score has a narrower range, with more than half of the hospitals in the CR rating receiving fewer than 50 points.
For example, while a perfect scoring hospital would get 100 points, the best performing CR hospital, 272-bed Billings Clinic in Billings, MT, received 72 points and the worst performing organization, 119-bed Sacred Heart Hospital in Chicago, received 16.
Only 158 hospitals received a score of at least 60.
Hospitals had a tough time scoring well because of two major failings throughout the industry, those in readmissions and communication, CR said.
"Clear communication in the hospital is hard to come by: Almost 500 hospitals earned our lowest scores for communication about new medications and discharge plans and none earned our top score," CR said in a magazine article accompanying the hospital listings. "That's worrisome because drug errors in hospitals are common and sometimes serious, and poor discharge planning can lead to readmissions."
How CR metrics differ from Leapfrog's
Santa explains that CR wanted a different safety methodology that only used publicly available data and was easier for the public to understand. CR's new score differs from Leapfrog's in three key ways.
First, it includes CT imaging as a safety measure because CTs have the potential to unnecessarily expose patients to dangerous amounts of radiation, with each scan the equivalent of between 100 and 500 chest X-rays. Hospital Compare includes CT scanning rates on its website, but considers them as one way to measure resource utilization to evaluate costly waste.
Second, the CU score draws from Medicare's 30-day readmission rates as posted on Hospital Compare, considering that too is a safety measure.
"A readmission rate is the number one indication of the likelihood that you're going to go back into a hospital and be exposed to additional risk, and because we know one reason for readmissions are errors that occur during the first admission, including infections," Santa says. "Hospitals that get it right the first time won't expose you to that additional risk."
Third, CU includes results from the HCAHPS survey as a safety measure because they reflect whether the patient thought their use of medications was explained well when they left the hospital. "Obviously a lot of errors that occur are around medication usage," Santa says. "And we think it's alarming that so little use seems to be made of the patient as a source of this information."
Leah Binder, President and CEO of the Leapfrog Group, said Leapfrog worked closely with CU, which uses some Leapfrog data in its methodology, and will continue to do so.
"We believe the two ratings complement each other and enrich the quality of information available to people making life and death decisions about their health care," she said in a statement.
The Leapfrog Group, which is supported by employers who purchase healthcare services for their employees, depends on hospitals to voluntarily report on certain Leapfrog specific measures, such as the frequency with which they use computerized provider entry systems.
Perhaps because it works collaboratively with hospitals, the Leapfrog scorecard drew heated criticism from hospital trade organizations, which accused Leapfrog of manipulating statistics, biasing its results by overweighting measures submitted by Leapfrog's participating hospitals, and not informing hospitals about the new score—criticisms that Binder refuted.
The American Hospital Association, which represents more than 5,000 hospitals, could not be reached for comment on the CU score because of the holiday.
Santa says his organization did not notify the AHA that its new scorecard was coming. And he anticipates that it and other hospital trade groups may react negatively to the magazine's new safety score as well. But unlike Leapfrog, CR only used publicly reported data. "The culture of Consumer Reports is very much a culture of independence," Santa says.
A quick look at how some hospitals scored under both methodologies reveals that many hospitals that did well on the Leapfrog survey did not fare as well on the CU safety score, and vice versa.
For example, Lake Regional Health System in Osage Beach, MO and Our Lady of the Resurrection Medical Center in Chicago both received a B from Leapfrog, but received CU's third and fifth lowest safety score of 22. And Massachusetts General Hospital, which earned an A on Leapfrog, received a safety score from CU of 45.
Bon Secours St. Francis Health System in Greenville, SC, received a B from Leapfrog, but it was the ninth safest hospital in the CU score. Memorial Hospital of Union County in Marysville, OH, was the 10th safest hospital in the CU score, but received a C grade from Leapfrog.
By category, here's what the CU scoring system consists of, and weights for each:
1. Deadly Infection—20%
CU rated hospitals by rates of catheter-associated central line bloodstream infections in intensive care units and some surgical site infections, and found that 202 hospitals reported infection rates higher than the national benchmark and "only 148 reported zero infections."
The data came from reports from 18 states that require infection rate reporting and from voluntary reports to the Leapfrog Group.
2. Radiation overload from imaging— 20%
According to a physician CR interviewed for the magazine article, far too many hospitals double-scan patients with CT, once without contrast and once with, although only 1% of patients need double scans, which dramatically increase radiation. Yet only 28% of hospitals in the CR rating had double-scan rates of 5% or less, the cutoff CR determined for a top rating. Radiation from CT scans, which are 100 to 500 times a chest X-ray, "might contribute to an estimated 29m000 future cancers a year," the advocacy group said.
3. Readmissions— 20%
Saying that up to 75% of hospital readmissions may be preventable, CR gave 166 hospitals its lowest score and none received a high score in this category.
4. Communication—20%
This was drawn from answers to HCAHPS survey questions such as whether doctors and nurses discussed new medications, asked if they'd need help when they got home, and whether they felt they were treated with courtesy and respect. Nearly half of the hospitals "earned CR's lowest score for communication about new medications and discharge plans," CR said in a statement.
5. Avoiding Complications—10%
This is based on hospital-acquired complications and adverse events following surgeries, procedures, and childbirth.
6. Avoiding Mortality—10%
Mortality is based on a set of 18 measures of inpatient mortality following certain procedures and medical conditions
Each of these two categories is based on the Agency for Healthcare Research and Quality's (AHRQ) patient safety indicators and patient quality indicators. Both are derived from what is posted on Hospital Compare.