Hospital
report cards: Making the grade
(This article was first printed in the June
2004 issue of the Harvard Health Letter.
For more information or to order, please go
to www.health.harvard.edu/health.)
These days, hospitals — like students — have
to worry about getting a bad report card. Employer
groups, health insurers, government agencies,
and even newspapers are amassing mountains of
data about them, crunching the numbers, and assigning
scores and rankings. Several private companies
have turned the collecting and assembling of
hospital data for public consumption into a nice
little business. Patients and their families
are increasingly expected to act like savvy shoppers,
making smart choices based on all this computerized
wisdom.
That’s the idea, anyway. Reality isn’t
quite so simple. There’s no easy way to
summarize quality. You get at it indirectly through
what can be measured; but the individual measurements
have problems. Mortality rates must be adjusted
to take into account how sick patients were to
begin with, and adjustment formulas vary. Patient
volume is often used to judge quality because
it’s easy to calculate. Studies have shown
an association between volume and better outcomes,
but it’s not a perfect correlation by any
means. Any overall grade is based on assumptions
about the relative importance of individual measurements — assumptions
that are open to question.
There are practical problems, too. The information
used to create the report cards is often years
out of date because of lags in the release of
data from Medicare and other government agencies.
Participation is often voluntary, and some hospitals
have balked at providing information.
A 1999 Institute of Medicine (IOM) report on
medical errors sparked this interest in grading
hospitals. The sound bite version of the report:
At least 44,000 and as many as 98,000 Americans
die each year from preventable medical errors
committed in hospitals. Putting information in
the hands of the public was supposed to be part
of the solution. It should be, but now we have
competing report cards and perhaps some information
overload. Whether these report cards will be
used to restrict access to certain hospitals
is another issue.
We’ve thumbnailed six of the hospital
report card services below. But if you’re
interested in these quality measurements, you
should get on the Web sites yourself. That’s
really the best way to get comfortable with this
kind of information.
How credible are the report cards and rating
systems? They each fall short in some way. And
they’re certainly not the only thing to
go by when you’re picking a hospital — or,
by extension, a doctor. Think of them as pieces
in the puzzle. And we’d still ask around
to see if people think it’s a good hospital.
U.S. News & World Report
www.usnews.com
The news magazine started ranking hospitals
in 1990, and the winners love to brag that they’re
at the top of the standings. The top 50 hospitals
in 17 specialties are listed. Searching on the
Web site is free. But the magazine’s rankings
put great weight on “reputational scores” calculated
from surveys of doctors. Is that anything more
than conventional wisdom? Bigger also tends to
get rated better because hospitals are graded
partly on how much high-tech equipment and how
many services they provide.
Leapfrog Group
www.leapfroggroup.org
Large employers started Leapfrog after the IOM
report came out. The stated goal is to use their
purchasing power — and consumer choice — to
get hospitals to reduce errors and improve overall
quality. The group first asked hospitals to supply
information on patient volume, computerized drug
ordering, and several other items. Now it is
surveying them about 30 safety practices that
will be combined into an overall safety score.
Access to the Web site is free, but you have
to click through several pages before you get
to information about a particular hospital. Participation
is voluntary, so you may not find anything about
the hospital you’re interested in.
Consumer Checkbook
www.checkbook.org
Consumer Checkbook is a consumer publisher and
Web site supported by the Center for the Study
of Services, a Washington, D.C., nonprofit organization.
Its guide includes “desirability” ratings
for hospitals based on surveys of physicians,
risk-adjusted mortality figures, and adverse
outcome rates for several surgical procedures.
The desirability scores are just a matter of
physician opinion. The mortality and outcome
information is based on 1996–99 Medicare
data, so it’s out of date. The Web version
of the guide can be hard to follow. The guide
costs $19.95, either in print or through the
Web site.
Health Grades, Inc.
www.healthgrades.com
Health Grades, a Lakewood, Colo., company, uses
a five-star grading system based largely on mortality
data from Medicare. It doesn’t give hospitals
overall scores, but rates them by individual
procedures and conditions; a hospital could get
five stars for coronary bypass, but just one
for hip replacement. Health Grades has been criticized
for keeping its formula for adjusting mortality
rates a secret. Yale researchers evaluated the
company’s report cards in a paper published
in 2002. Over all, higher ratings by Health Grades
correlated well with better care, but researchers
also found marked differences between hospitals
with the same rating. Access to the Web site
is free.
National Voluntary Hospital Reporting Initiative
www.medicare.gov/hospital/home.asp
This is Medicare’s foray into hospital
quality rating. So far, three conditions are
covered: heart attack, heart failure, and pneumonia.
Hospitals have been asked to provide information
on certain aspects of care for those conditions — for
example, the percentage of heart attack patients
that receive an aspirin upon arrival. Each hospital’s
performance is compared with results for the
top 10% and 50% of hospitals. For example, if
99% of heart attack patients at the top 10% of
hospitals get an aspirin upon arrival, but only
70% of the patients at your hospital do, maybe
heart attack care at your hospital isn’t
what it should be. This is just a pilot project,
so many hospitals aren’t listed. It would
be helpful to have some explanation for why these
particular aspects of care are important.
Select Quality Care
www.selectqualitycare.com
Select Quality Care is a Web site developed
by HealthShare Technology, an Acton, Mass., company.
Unlike the other sites on this list, it’s
not accessible to the public — only to
people enrolled in health plans that HealthShare
has contracts with. At least one other company
is selling a similar, members-only report card
Web site to health plans. One nice feature of
the site is that the hospital rankings depend
on how you personally rate the importance of
patient volume, mortality rates, and several
other factors. If you revise your preferences
you can see how it affects the rankings. The
site also has graphics that make the averages
for your area clear, so you can easily tell whether
a hospital falls above or below the mean.
(This article was first printed in the June
2004 issue of the Harvard Health Letter.
For more information or to order, please go
to www.health.harvard.edu/health.)
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