America’s Best Hospitals – Many Others are Just as Good

America’s Best Hospitals. Who among us does not like lists that direct us to the best hospitals, the best doctors, the best colleges? For 16 years the weekly news magazine U.S. News & World Report has published an annual list of the top 50 hospitals in the country by area of specialty. Its popularity continues to grow despite some major gaps in the information sources used in its ranking system, which is based in large part on perception rather than hard evidence.

It has been eight years since we reported anything about this topic. The impetus for that article was a devastating critique of the methodology used by USN&WR, which was published in 1997 in the Journal of the American Medical Association. Its lead author Jesse Green, PhD, New York University, told HealthFacts: “For the consumer, what’s offered by USN&WR is less than what they claim it to be, and that is the major problem. They’ve patched together data from a number of fairly unreliable sources, and with a magic formula, they come up with a score. None of it’s worth the paper it’s printed on, frankly.”

In 1999, the New England Journal of Medicine published a study by J. Chen, MD, and colleagues at Yale. It was the first to look at the question of whether Medicare enrollees treated at the top-ranked hospitals on the USN&WR list were more likely to survive a heart attack than those admitted to other hospitals. The answer was yes, with the lion’s share of the credit going to greater adherence to evidence-based guidelines that recommend the use of aspirin and beta-blockers (see next page).

Little else had been done to validate the purportedly superior performance of “America’s Best Hospitals” until last month. A new study has found the “best” cardiac hospitals ranked by USN&WR had provided appropriate care—most of the time—for people admitted for a heart attack or heart failure. But it also found that these hospitals were often outperformed or equally matched by many hospitals that never made the list.

774 Hospitals in the Study

The new study, published in the American Heart Association’s journal Circulation, was conducted by Scott C. Williams, PsyD, and colleagues at the Joint Commission on Accreditation of Healthcare Organizations. The JCAHO researchers set out to determine how often the top-ranking cardiac hospitals on the USN&WR list were delivering quality care to their patients with heart attack or heart failure. For comparison purposes, 774 hospitals were included in this study with 41 of them in the top 50 cardiac hospitals on the USN&WR list. (Nine of the 50 hospitals failed to supply complete data on their patients treated for heart attack or heart failure.)

The JCAHO researchers applied the following performance measures of quality care, which were established years ago by the American College of Cardiology and the American Heart Association. Note how simple and low-tech virtually all are:

For Both Heart Attack and Heart Failure Patients

-Aspirin given within 24 hours of arrival

-Beta blocker given within 24 hours of arrival (Beta-blockers are a class of drugs that decrease the heart's need for blood and oxygen by reducing its workload. They are sold under numerous different brand and generic names.)

-aspirin therapy and beta-blocker therapy prescribed at discharge

- Angiotensin-converting enzyme (ACE) inhibitor therapy prescribed at discharge to patients with left ventricular systolic dysfunction (ACE inhibitors belong to the class of high blood pressure drugs sold under multiple brand and generic names.)

-Smoking cessation advice/counseling

Additional Measures for Heart Failure Patients

-Assessment of left ventricular function (with echocardiography or radionuclide ventriculography)

-Instructions at discharge about drugs, diet, weight, symptoms worsening, follow-up, and physical activity

These performance measures are all based on published evidence that clearly demonstrates effectiveness. For example, numerous studies have shown that giving aspirin as early as possible to someone having a heart attack not only reduces adverse “events” but also mortality. All 774 hospitals in this study were accredited by the JCAHO; all had supplied relevant information in 2004 as part of the accrediting process.

Drawing from administrative and discharge information supplied by the hospitals, the JCAHO researchers found that the 41 top-ranked USN&WR cardiac hospitals “provided care that was consistent with evidence-based practice guidelines 86% of the time, on average… In comparison, the other 733 hospitals in the study provided care that was consistent with practice guidelines 83% of the time.”

But the superiority of the USN&WR list was challenged by these findings: 13 hospitals not on this list did better than any of the 41 top-ranked hospitals. And 313 non-ranked hospitals did better than half of those on the USN&WR list. “The fact that so many hospitals did as well or better than those ranked at the top by USN&WR is good news for many Americans who may not have access to those highly rated institutions,” concluded Dr. Williams and colleagues at the JCAHO.

Asked for the take-home message from his study, “We’re not knocking any hospitals on the USN&WR list. Hospital quality assessment is a complex issue,” answered Dr. Williams in a telephone interview. (His study does not identify any hospitals by name.) “For the first time, there are data available [to the public] for how hospitals comply with evidence-based measures for cardiac care.”

Sources of information about U.S. hospitals

For the longest time the USN&WR was the only game in town for anyone who wanted independent information about hospitals. Of the following Web sites only the Leap Frog Group provides information in a consumer friendly format.

-JCAHO Web site (www.qualitycheck.org);

-the Leapfrog Group (www.leapfroggroup.org);

-and the U.S. Health and Human Services (www.hospitalcompare.hhs.gov/hospital/home2.asp).

*Nine out of the 50 hospitals failed to supply complete data on their patients treated for heart attack or heart failure.

Maryann Napoli, Center for Medical Consumers, September 2006