TUESDAY, March 12, 2002 (HealthDayNews) -- You have a choice between hospitals in town, and you head to the Internet to check their respective rankings. One gets five stars, the other just one, so the decision should be easy.
Think again. A new study says hospital "report cards" that rely on billing records and death rates bring home mediocre marks at separating fair care from excellent care. Although highly ranked hospitals as a group may deliver better treatment than laggards, between individual institutions the ratings often go the other way.
"Is this information better than no information? Well, just a little bit, and probably not as much as people think," says Harlan M. Krumholz, a Yale University cardiologist and lead author of the study. "The best thing at this point is still word of mouth and reputation."
The findings, which appear in tomorrow's Journal of the American Medical Association, are a red flag for policy makers who are now trying to create a ranking system for U.S. hospitals, Krumholz says.
"I strongly favor performance data, but people need to understand clearly what the limitations are of the methodology and the data of this approach. It has potential hazards," he says.
Krumholz and his colleagues evaluated the medical records of nearly 142,000 men and women age 65 and over who were treated for heart attacks at 3,363 hospitals nationwide between 1994 and 1996. The patients were enrolled in Medicare, the government's insurance plan for the elderly.
The researchers determined whether patients were given a checklist of heart-helping therapies, such as aspirin, beta blockers and angiotensin-converting enzyme (ACE) inhibitors, as well as procedures to improve blood flow, including angioplasty and clot-busting drugs. They also considered 30-day death rates, the presumptive gold standard for quality.
Krumholz's group then compared their own evaluation to ratings published by Health Grades Inc., an online service that ranks hospitals on a five-star scale. The ratings include mortality data and information on billing sheets, which are a rough proxy for the care patients receive.
Nearly three-quarters of Health Grades' hospitals had three-star rankings; 7.6 and 7.8 percent got one and two stars, respectively; and 10.6 percent earned five stars. There were no four-star clinics. The company has since switched to a one-, three-, and five-star scale.
On average, patients treated at hospitals with five-star rankings were more likely to receive aspirin and beta blockers both on admission and at discharge. However, they weren't significantly more likely to be given ACE inhibitors, which are widely considered to be under-prescribed.
Highly ranked hospitals also had lower 30-day death rates than the other facilities, with about 22 percent of patients dying at one-star clinics, versus 16 percent at five-star hospitals.
Yet on an individual basis, the rankings broke down. Middling hospitals often provided better care than top-ranked facilities. In addition, one-star facilities occasionally had lower mortality rates than their five-star counterparts.
"It can be quite difficult to discriminate between hospitals on the basis of quality. There's a lot of overlap between individual hospitals," says Dr. Martha J. Radford, director of clinical quality at Yale New Haven Health System and a co-author of the study. "The quality measurement that's available using administrative data is somewhat limited."
Krumholz says one failure of relying on mortality statistics is that small, low-volume hospitals may be unfairly tagged because of simple bad luck.
"Things don't always go well," he says. "We have to be careful not to penalize hospitals that are poorly rated, but actually may be providing excellent care."
Kerry Hicks, chief executive officer of Health Grades, defends his company's services and calls the latest study "dated" and flawed. Hicks also notes Health Grades has modified its ratings in recent years to squeeze more information from billing records.
Despite the study's problems, Hicks notes it still found a difference between high- and low-rated hospitals, and says the 6 percent difference in mortality between one- and five-star hospitals was "extremely meaningful" for patients.
"We believe that better-informed, better-educated consumers have better outcomes. I don't care whether it's buying a car or getting health care," he says.
What To Do
Should you ignore hospital rankings altogether? Again, not so fast.
"You do know more than if you knew nothing, which is where most consumers are at to begin with," says Judith Hibbard, a health policy expert at the University of Oregon in Eugene. "You've increased your probability of making a good choice."
For more on the quality of health care in the United States, try the Agency for Healthcare Research and Quality or the Joint Commission on Accreditation of Healthcare Organizations.
Learn more about Health Grades, which has about 1 million users a year.
