The magazine's renowned list of 50 top-ranked hospitals for cardiovascular care outperformed 3,500 non-ranked hospitals on key metrics, but saw similar or higher readmissions rates.
It turns out there may be more to the U.S. News & World Report top hospital rankings than a savvy marketing gimmick.
In a study in JAMA Cardiology, Harvard University researchers examined the list's top 50 hospitals for cardiovascular care and found that, yes indeed, they had lower 30-day mortality rates for heart attack, heart failure, and coronary artery bypass grafting, along with higher patient satisfaction ratings when compared with non-ranked hospitals.
However, 30-day readmission rates for heart attack and CABG were either similar or higher in the top 50 hospitals.
Study co-author Deepak L. Bhatt, MD, MPH, a cardiologist, professor at Harvard Medical School, and executive director of interventional cardiovascular programs at Brigham and Women's Hospital, says that the higher readmissions rate is not necessarily a black mark for the top hospitals, or the magazine, but more of an indication that 30-day readmissions is a lousy quality metric.
Bhatt spoke with HealthLeaders about the study. The following is an edited transcript.
HL: Did your study validate the U.S. News rankings?
Bhatt: Yes, we did! There's been a debate, certainly among hospital circles, about whether the U.S. News & World Report rankings are or aren't valid in terms of determining which hospitals are truly the best.
First of all, every hospital wants to be on that list, even if they say otherwise. But the question remains, is it just a marketing thing or is there any validity to it? What we found out was, in fact, U.S. News best hospitals do have better outcomes. The list actually does mean something.
I didn't personally go in with any bias. I would have been happy either way. In fact, if anything I was a little skeptical. But, data are what they are, and they show that the U.S. News really does correlate with better outcomes. Not just better processes, not just better metrics, but actual better outcomes, and it's hard to argue with that.
HL: Your study also raises concerns about the value of readmissions as a quality metric. Please elaborate.
Bhatt: There are two messages from this paper that are valid but are completely disconnected.
One is that the U.S. News top-ranked hospitals list is a valid surrogate of outcome. It really does reflect which hospitals are providing better care that results in better outcomes. That's message number one.
Completely distinct from that message is that the measure of readmissions, in particular readmissions for heart failure, is not a valid metric of hospital performance. Hospitals are penalized if they readmit too many of their heart failure patients. It's something that hospitals watch very closely. They try to make that number better. What we found was no correlation between the good hospitals and their readmission rate for heart failure.
It makes sense on a common sense level. To take it an extreme, if all your heart failure patients are going home and dying, then none of them will get readmitted so your readmission rate will be zero and that metric will look good. Unfortunately, from the patient's perspective, it's a failure, so that's why readmission in general can be a flawed metric.
That's not to say readmission isn't important. That ideal scenario is to reduce both mortality and readmissions, but you don't want it to be a trade-off where you're potentially reducing readmissions but not influencing or even worsening mortality.
HL: Do you think these top hospital rankings adequately address patient acuity?
Bhatt: In general, teaching hospitals tend to be located in the city or inner cities, tend to get sicker patients, tend to get patients that are more likely to be indigent.
We looked at risk standardized mortality. To the extent possible, there was risk standardization of mortality performed by CMS themselves. We weren't just looking at crude mortality. It was, to the extent possible, risks standardized, acknowledging that those risks standardizations aren't perfect either.
HL: Why did your study focus on cardiac?
Bhatt: The most-honest answer is because I'm a cardiologist. Other than that mundane reason, it's also because, in terms of healthcare and common conditions, common causes of mortality, the leading cause of mortality still nationwide and in most regions of the world is cardiovascular disease.
In terms of expense, as far as U.S. healthcare costs, cardiovascular and cancer account for a good chunk of it. So, for reasons of healthcare mortality, morbidity and cost, cardiovascular is probably right there at the top.
HL: Do you think your findings would be similar if you looked at outcomes for other specialties?
Bhatt: What we found likely would be true, somewhat, if you looked for other things like cancer or respiratory diseases or whatever.
HL: What do you think would be the best use for your findings?
Bhatt: First of all, I'd say the U.S. News is worth paying attention to, both if you are a patient, but also for hospitals. Though many hospitals don't like to admit it, they do spend a lot of time thinking about their own rankings, and maybe that's not such a bad idea. There's something to it.
But the second more important message is we've really got to move away from penalizing financially for readmissions, because it creates a potentially very perverse disincentive. It's better to focus on quality measures and metrics where we can really improve patient care instead of on ones that might unintentionally be hurting patient care.
HL: How would this perverse disincentive manifest itself?
Bhatt: I'm not suggesting that an individual doctor is going to say, "I'm going to discharge you, even though you should be admitted, even if you're going to die." I don't believe doctors are going to behave in that unethical fashion.
It's not a doctor level thing. It's a healthcare system and hospital-level thing, where if a significant financial penalty is being enacted, it's naive to think that that's not going to influence behavior on a macro level. Of course it does.
“Is it just a marketing thing or is there any validity to it? What we found out was, in fact, U.S. News best hospitals do have better outcomes. The list actually does mean something.”
Deepak L. Bhatt, MD, cardiologist and professor at Harvard Medical School,
John Commins is a senior editor at HealthLeaders.
The top 50 cardio hospitals had lower 30-day mortality for heart attack, heart failure and coronary artery bypass grafting, and higher patient satisfaction scores.
However, 30-day readmission rates for heart attack and CABG were similar or higher in top 50 hospitals.
The findings suggest that readmissions are a bad quality metric that create perverse incentives to discourage readmissions.