Key Points
Question
Do US News & World Report top-ranked hospitals for cardiovascular care have better outcomes than nonranked hospitals?
Findings
In this cross-sectional study, US News & World Report top-ranked hospitals for cardiovascular care had lower 30-day mortality rates for acute myocardial infarction, heart failure, and coronary artery bypass grafting and higher patient satisfaction ratings compared with nonranked hospitals. However, 30-day readmission rates were either similar (for acute myocardial infarction and coronary artery bypass grafting) or higher (for heart failure) at top-ranked hospitals compared with nonranked hospitals.
Meaning
The observed discrepancy between readmissions and other performance measures raises concern that readmissions may not be an adequate metric of hospital care quality.
Abstract
Importance
The US News & World Report (USNWR) identifies the “Best Hospitals” for “Cardiology and Heart Surgery.” These rankings may have significant influence on patients and hospitals.
Objective
To determine whether USNWR top-ranked hospitals perform better than nonranked hospitals on mortality rates and readmission measures as well as patient satisfaction.
Design, Setting, and Participants
This national retrospective study evaluated outcomes at 3552 US hospitals from 2014 to 2017.
Exposures
US News & World Report 2018 to 2019 Cardiology and Heart Surgery rankings (top-ranked vs nonranked hospitals).
Main Outcomes and Measures
Hospital-level 30-day risk-standardized mortality and readmission rates for Medicare fee-for-service beneficiaries age 65 years or older hospitalized for 3 cardiovascular conditions: acute myocardial infarction (AMI), heart failure (HF), and coronary artery bypass grafting (CABG) as well as Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction star ratings obtained from publicly available Centers for Medicaid and Medicare Services data.
Results
Thirty-day mortality rates at top-ranked hospitals (n = 50), compared with nonranked hospitals (n = 3502), were lower for AMI (11.9% vs 13.2%, P < .001), HF (9.5% vs 11.9%; P < .001), and CABG (2.3%vs 3.3%; P < .001). Thirty-day readmission rates at the top-ranked hospitals (n = 50) when compared with nonranked hospitals (n = 2841) were similar for AMI (16.7% vs 16.5%; P = .64) and CABG (14.1% vs 13.7%; P = .15) but higher for HF (21.0% vs 19.2%; P < .001), Finally, patient satisfaction was higher at top-ranked hospitals (n = 50) compared with nonranked hospitals (n = 3412) (3.9 vs 3.3; P < .001).
Conclusions and Relevance
We found that USNWR top-ranked hospitals for cardiovascular care had lower 30-day mortality rates for AMI, HF, and CABG and higher patient satisfaction ratings compared with nonranked hospitals. However, 30-day readmission rates were either similar (for AMI and CABG) or higher (for HF) at top-ranked compared with nonranked hospitals. This discrepancy between readmissions and other performance measures raises concern that readmissions may not be an adequate metric of hospital care quality.
This cross-sectional study examines 30-day risk-standardized mortality rates for coronary artery bypass grafting, acute myocardial infarction, and heart failure at top-ranked US News & World Report cardiology vs nonranked hospitals.
Introduction
Hospital rankings that evaluate and publicly compare hospital performance for cardiovascular care have become increasingly common as part of a movement to enhance transparency in health care. The US News & World Report (USNWR) is one of the most influential rankings and identifies the “Best Hospitals” for “Cardiology and Heart Surgery” among other categories.1 Hospital rankings should guide patients to high-quality health care, which can be measured by outcomes that matter most to patients, such as mortality rates and readmissions. However, the USNWR hospital-ranking methods also emphasize metrics, such as hospital reputation, that may not reflect care quality. While prior research has shown that top-ranked hospitals may perform better than nonranked hospitals, these studies were for a specific subset of patients, such as those undergoing percutaneous coronary intervention,1 or were performed nearly a decade ago.2,3,4 These findings may no longer hold true, as hospitals have increasingly been required to participate in national quality improvement initiatives, such as pay-for-performance, public reporting, and readmission reduction programs, and because the USNWR methods have evolved in recent years.5,6
Understanding whether USNWR top-ranked hospitals perform better than nonranked hospitals on mortality rates and readmission measures is important given the significant influence that these rankings may have on patients and hospitals. This study examined whether USNWR top-ranked hospitals compared with nonranked hospitals have better outcomes as assessed by mortality rates, readmission rates, and patient satisfaction for 3 cardiovascular conditions. This study also evaluated, among hospitals that were ranked, whether a higher ranking was associated with better outcomes.
Methods
We obtained hospital-level risk-standardized 30-day mortality rates and readmission rates for acute myocardial infarction (AMI), heart failure (HF), and coronary artery bypass grafting (CABG) from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare Data set.7 Risk standardization of mortality and readmission rates is performed by CMS to account for variation in patient case mix indices among hospitals.8 We also obtained Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) star ratings, which are a composite measure of patient satisfaction for each hospital (assigned 1-5 stars).7
Hospitals were stratified into 2 groups: top-ranked hospitals (defined as those in the top 50 of the 2018-2019 USNWR “Best Hospitals” for “Cardiology and Heart Surgery”) and nonranked hospitals (defined as those not identified as top-50 hospitals). We then compared risk-standardized 30-day mortality and readmission rates between top-ranked and nonranked hospitals for the 3 cardiovascular conditions as well as HCAPHS star ratings at these hospitals using a linear regression model.
Additionally, we divided the top 50 ranked hospitals into quintiles by hospital rank (1-10, 11-20, 21-30, 31-40, and 41-50). We then compared the aforementioned outcome measures by hospital quintile using a linear regression model to evaluate if, among top-ranked hospitals, a higher rank was associated with better outcomes.
Results
Thirty-day mortality rates at top-ranked hospitals (n = 50) compared with nonranked hospitals (n = 3502) were lower for AMI (11.9% vs 13.2%; P < .001), HF (9.5% vs 11.9%; P < .001), and CABG (2.3% vs 3.3%; P < .001) (Figure 1A). In addition, 30-day readmission rates (Figure 1) at top-ranked hospitals (n = 50) compared with nonranked hospitals (n = 2841) were similar for AMI (16.7% vs 16.5%; P = .64) and CABG (14.1% vs 13.7%; P = .15), but higher for HF (21.0% vs 19.2%; P < .001). Finally, patient satisfaction was higher at top-ranked hospitals (n = 50) compared with nonranked hospitals (n = 3412) (3.9 vs 3.3; P < .001) (Figure 2).
Figure 1. Mortality Rates and Readmission Rates at Top-Ranked vs Nonranked Hospitals.
Thirty-day mortality rates (A) and readmission rate (B). AMI indicates acute myocardial infarction; HF, heart failure; CABG, coronary artery bypass grafting.
Figure 2. Patient Satisfaction Scores at Top-Ranked vs Nonranked Hospitals.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) patient satisfaction star rating (1-5).
Among the top 50 ranked hospitals, 30-day mortality rates at the top-ranked quintile (1-10) vs the lowest-ranked quintile (41-50) were lower for 2 of the 3 conditions (AMI, 10.5% vs 12.5%; P < .001; HF, 8.2% vs 10.7%; P = .001; CABG, 2.0% vs 2.4%; P = .23) (Table). Thirty-day readmission rates at top-ranked vs lowest-ranked quintile hospitals did not significantly differ for any of the 3 cardiovascular conditions (AMI, 17.4% vs 16.2%; P = .11; HF, 21.0% vs 20.5%; P = .73; CABG, 13.8% vs 13.4%; P = .49). Patient satisfaction, as measured by the HCAPHS star rating, was higher at the top-ranked quintile vs the lowest-ranked quintile hospitals (4.2 vs 3.8; P = .01).
Table. Outcomes by Quintile Among Ranked Hospitals.
| Rate | USNWR Rank | |||||
|---|---|---|---|---|---|---|
| 1-10 | 11-20 | 21-30 | 31-40 | 41-50 | P Value for Trend | |
| Mortality | ||||||
| AMI | 10.5 | 11.6 | 12.8 | 12.2 | 12.5 | <.001 |
| HF | 8.2 | 9.6 | 9.6 | 9.5 | 10.7 | .001 |
| CABG | 2.0 | 2.5 | 2.4 | 2.4 | 2.4 | .23 |
| Readmission | ||||||
| AMI | 17.4 | 16.9 | 16.7 | 16.1 | 16.2 | .11 |
| HF | 21.0 | 21.0 | 20.9 | 21.7 | 20.5 | .73 |
| CABG | 13.8 | 14.3 | 15.2 | 13.5 | 13.4 | .49 |
| Satisfaction (HCAPHS star) | 4.2 | 4.2 | 4.0 | 3.7 | 3.8 | .01 |
Abbreviations: AMI, acute myocardial infarction; CABG, coronary artery bypass grafting; HCAHPS, the Hospital Consumer Assessment of Healthcare Providers and Systems; HF, heart failure; USNWR, US News & World Report.
Discussion
Our findings demonstrate that 30-day risk-standardized mortality rates for CABG, AMI, and HF at top-ranked USNWR cardiology hospitals are lower than at nonranked hospitals. In contrast, 30-day risk-standardized readmission rates for AMI and CABG are similar at top-ranked compared with nonranked hospitals, while HF readmissions are significantly higher. Finally, we also found that patient satisfaction scores were higher at top-ranked USNWR cardiology hospitals compared with nonranked hospitals.
Although the USNWR methods have changed in recent years, top-ranked cardiology hospitals have lower mortality rates and higher patient satisfaction scores compared with nonranked hospitals. This likely reflects the fact that 37.5% of USNWR rankings are based on raw mortality data that are obtained from the CMS, although the approach to risk adjustment is different than that of the CMS’ risk standardization.9 However, readmission rates are similar for AMI and CABG at top-ranked vs nonranked hospitals and are higher for HF at top-ranked hospitals. This disconnect between mortality rates and readmission outcomes at top-ranked hospitals compared with nonranked hospitals highlights the ongoing uncertainty as to whether readmissions rates are an adequate surrogate for quality of care,10 particularly for cardiovascular conditions, such as HF.6,11
In recent years, financial incentives for hospitals to reduce readmissions following the enactment of the Hospital Readmissions Reduction Program have been 10-fold to 15-fold greater than incentives to improve mortality rates and have resulted in significant declines in cardiovascular readmissions.12 Our finding that top-ranked hospitals have lower mortality rates than nonranked hospitals but have generally similar readmission rates might reflect these incentives. It is possible that top-ranked and nonranked hospitals have focused substantial resources on reducing readmissions rather than mortality rates given the financial push of the Hospital Readmission Reduction Program, which resulted in generally similar readmission rates but disparate mortality rates between these hospital groups.
Limitations
Our study has limitations. We chose to use USNWR hospital rankings, which use CMS data to determine the rankings. Other hospital ranking systems use all-payer data, which capture non-Medicare patients and result in different hospital rankings than USNWR.13
Conclusions
We found that USNWR top-ranked hospitals for cardiovascular care had lower 30-day mortality rates for AMI, HF, and CABG and higher patient satisfaction ratings compared with nonranked hospitals. However, 30-day readmission rates were either similar (for AMI and CABG) or higher (for HF) at top-ranked compared with nonranked hospitals. This discrepancy between readmissions and other performance measures raises concern that readmissions may not be an adequate metric of hospital care quality.
References
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