Hospital Quality in America
Healthgrades

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History

In 1998, Healthgrades initiated objective quality research to evaluate hospital quality in America and recognize top-performing hospitals that have achieved quality excellence in particular specialties, clinical excellence, and patient safety. The report focus is to inform consumer decisions with accumulated data regarding clinical outcomes, patient satisfaction, patient safety, and health conditions from reputable online resources.

Healthgrades information includes more than 900,000 physicians in all 50 states and the District of Columbia.

Scope of Report

Report’s Intended End Users

Healthgrades evaluates hospitals solely on clinical outcomes—risk-adjusted mortality and in-hospital complications— to help consumers understand, compare and evaluate hospital performance.

Understanding the Score

Ranking

Healthgrades recognizes the best performer hospitals in two categories:

  • America’s 50 Best Hospitals are the top 1% of hospitals in the nation for providing overall clinical excellence across a broad spectrum of conditions and procedures consistently for a minimum of seven consecutive years.
  • America’s 100 Best Hospitals are the top 2% of hospitals in the nation for exhibiting clinical excellence for at least four consecutive years.

Reporting

Healthgrades generates this annual report using Medicare inpatient data from the Medicare Provider Analysis and Review (MedPAR) database, purchased from the Centers for Medicare and Medicaid Services (CMS), for the previous three years. For example, the report released for 2014 uses data from 2011 through 2013.

Inclusions

Inclusions vary based on measures and award categories such as Hospital Quality/Mortality, Bariatric Surgery, Maternity Care and Gynecologic Surgery, Women’s Health, Patient Safety, Outstanding Patient Experience, America Best Hospitals, and Hospital Quality and Clinical Excellence. Overall inclusions are as follows:

  • Nation’s acute care, critical access, Veteran’s Affairs (VA), and Children’s hospitals
  • Medicare-certified
  • 33 listed in-hospital procedures and conditions
  • At least 30 cases across three years of data and at least five cases in the most recent year

Exclusions

Exclusions vary based on measures and award categories such as Hospital Quality/Mortality, Bariatric Surgery, Maternity Care and Gynecologic Surgery, Women’s Health, Patient Safety, Outstanding Patient Experience, America Best Hospitals, and Hospital Quality and Clinical Excellence. Overall exclusions are as follows:

  • Patients who left the hospital against medical advice or who were transferred to another acute care hospital.
  • Patients discharged alive with a length of stay that is inconsistent with the reason for Admission.
  • Patients who were still in the hospital when the Medicare claim was filed.
  • Patients with an invalid gender-related procedure (e.g., a prostatectomy related to a female patient).
  • Patients who have had any organ transplant.
  • Patients in medical cohorts1 who were discharged to hospice.
  • Patients in medical cohorts1 with metastatic cancers.
1. Medical cohorts include non-surgical cohorts: bowel obstruction, chronic obstructive pulmonary disease, diabetic, emergencies, gastrointestinal bleed, heart attack, heart failure, hip fracture treatment, pancreatitis, pneumonia, pulmonary embolism, respiratory failure, sepsis, and stroke.

Data Source

  • Medicare inpatient data from the MedPAR database purchased from CMS.

Methodology

http://www.healthgrades.com/quality

Healthgrades communicates performance through star ratings. Star ratings are an evaluation of the hospital’s actual performance as compared to the predicted performance for that hospital based on a specific risk-adjustment model applied to that hospital.

Healthgardes analysis is based on the most recent three-year time period available. The data measures are adjusts for each patient’s risk factors, such as, age, gender, and medical condition. Healthgrades used logistic regression to determine which of these potential risk factors were statistically significant in predicting the outcome measure (e.g., mortality). All risk factors that remained in the final model were statistically significant at the p <0.05 level in predicting the clinical outcome.

Healthgrades hospital star performance ranking involves four steps:

  1. A predicted number of deaths or complications at each hospital is calculated by summing the individual patient record-predicted values determined from logistic regression models.
  2. The predicted hospital value is compared with the actual or observed value, which is the actual number of deaths or complications at each hospital.
  3. A test is conducted to determine whether the difference between the predicted and actual values was statistically significant. A z-score is used to establish a 90% confidence interval.
  4. Hospital performance star-levels were determined based upon the outcome of the test for statistical significance. A higher z-score means better performance.

Beginning with the 2015 award year, Mortality and Complications Methodology includes coefficient summary tables for 33 logistic regression models. For each model, tables include the following items:

  • Model (factor) Coefficient: This represents the increase or decrease to the patient level log odds when the patient has the associated factor.
  • Standard Error: This is a measure of variation for the coefficient.
  • Wald Score: This is a test statistic which provides a measure of the strength of the relationship between the factor and the outcome.
  • Odds Ratio: This is the most commonly interpreted component of a logistic regression model. This indicates the relative increase in the likelihood of a negative outcome when a patient has the risk factor relative to a patient who does not.

POA fill rates were included as an additional independent variable for each year of data. The POA fill rate was calculated as the percent of diagnosis codes having a known POA indicator value of Yes or No or Clinically Undetermined among patients in that cohort at that hospital

For each condition or procedure, hospital performance is evaluated and stratified into three categories:

Better Than Expected – Actual performance was better than predicted and the difference was statistically significant at alpha = 0.1.

As Expected – Actual performance was not statistically significantly different from what was predicted at alpha = 0.1.

Worse Than Expected – Actual performance was worse than predicted and the difference was statistically significant at alpha = 0.1.

A complete description of the methodology is available in the Healthgrades website. http://www.healthgrades.com/quality/archived-reports

Identifying America’s 50 Best Hospitals™

Healthgrades uses a two-step process to identify America’s 50 Best Hospitals™, also known as the top 1 percent of hospitals in the nation for consistent clinical quality.

  • Identified those hospitals that received the Distinguished Hospital Award for Clinical Excellence for at least eight consecutive years.
  • If the number of hospitals identified above was less than 50, then the recipients for the last seven consecutive years were identified and sorted by average z-score from the most recent Distinguished Hospital Award for Clinical Excellence analysis. (The average z-score is a statistical measure of hospital quality outcomes.) The top hospitals from this list were then added to the list from Step 1 above to complete a list of 50.
Identifying America’s 100 Best Hospitals™

Healthgrades America’s100 Best Hospitals™ award recognizes the top 100 hospitals that received the Distinguished Hospital Award for Clinical Excellence for at least the last four years. America’s 50 Best Hospitals™ is combined with the next 50 top hospitals, (ranked by consecutive years and average z-score), to generate America’s 100 Best Hospitals™. These hospitals are recognized as the top 2 percent in the nation for consistent clinical quality.

Measures

Healthgrades also awards hospitals in the following categories: Mortality, Bariatric Surgery, Maternity care & Gynecologic Surgery, Women’s Health, Patient Safety, Outstanding patient Experience, America’s Best Hospitals and Clinical Excellence. Each category includes different conditions and/or procedures with unique inclusions, exclusions, and measures.

Improvement Tools

Improvement tools and resources can be found at http://www.hqinstitute.org/tools-resources