Of the 102 hospitals that received a five-star rating, few are among the elite generally praised for great care. Major academic health centers did not shine. Is the star rating an unfair measure?
My hospital scored four stars, and we are no Cleveland Clinic. We do work hard. But we don’t take the sickest patients (we transfer to other facilities when our capabilities aren’t sufficient to care for a patient). High acuity patients can be incredibly complex and often therapies that are indicated in less complicated patients are not a wise choice for the critically ill. So, we can’t use our VTE prophylaxis bundle and must assume the risk of blood clots as smaller harm than intracranial hemorrhage. Their hospital stays can be many times longer than the average, increasing the chances for acquiring HAIs (hospital acquired infections) and pressure ulcers. Transferring to a higher-acuity major center, data-wise, is a sending a negative result across town by ambulance to another hospital’s spreadsheet.
Low-scoring large academic health centers treating our sickest patients would point out that they also treat our poorest patients. Socio-economic/demographic factors of course have influence on re-admission rates. This is one of seven measures, but has a weighted score of 22% in calculating the star rating. SO, much like schools in areas where kids are poor and hungry and the teachers spend a great deal of time figuring out how to keep them fed so they can stay awake long enough to learn an equation–making the idea of imposing the standardized testing of No Child Left Behind on that classroom and thinking it is an appropriate way to compare that school to the one in the next county where the average household income is $100,000/year and the PTA meetings are standing room only…well we know how that ended. Our large public hospitals are caring for patients with heart failure who can not read the discharge instructions, do not have access to transportation to get them to the follow up care that they don’t have the health insurance to pay for and can’t take the prescription drugs that they don’t have covered (in non-Medicaid expansion states). Maybe they also don’t have a grocery store in their neighborhood with a selection of food will keep their sodium intake at the strict low level needed to keep them from returning in a few weeks with an acute exacerbation. If that patient is 40% of your population, you have a challenge in front of you.
Good news is these low scores are really lighting a fire under hospital management. Even though right now it feels like the building is burning down a little. It is the hospital CEO’s prerogative to incorporate community building into his financial agenda (Star ratings aren’t tied to reimbursement, but they are composed of Medicare quality indicators that do affect how much the hospital gets from the Medicare-insured patients).
But the data. Where did this data came from and how just or unjust is it? My preliminary ruling is this is a treasure trove of information openly available to the public and I love that; but the population a hospital serves does have bearing on the score a hospital pulls. That doesn’t excuse the hospital from being rated. It points to where funding and research and pilot programs should be in place to address community health indicators, cause hospital walls are permeable.
If you want to go deep on the data, I encourage it! Go here. If you don’t feel like 40-odd pages of methodology and another government website, here are the two bits I found most helpful as points of reference for what was measured and how:
This chart (source):
and this quote (same source):
For example, in April 2015, OP-21 (Median Time to Pain Management for Fractures) had a national average performance of 55.6 minutes with a standard deviation of 17.75 minutes. In contrast, VTE-6 (Incidence of Potentially Preventable Blood Clots) had a national average of 7.23% with a standard deviation of 9.10%. After standardization and redirection, both measures had a mean score of 0 and standard deviation of 1; both were reversed so that a higher standardized score indicates better quality.
I’m just going to leave a few more links here.
https://www.medicare.gov/hospitalcompare/About/What-Is-HOS.html — Much more on quality measures.
https://data.medicare.gov/Hospital-Compare/Hospital-General-Information/xubh-q36u –The you-need-four-computer-screens-to-read spreadsheet with all the hospitals’ star ratings! SLICK!