Healthgrades Specialty State Rankings Methodology

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Click here for the full PDF of Healthgrades Specialty State Rankings Methodology

TABLE OF CONTENTS

Performance Measurement:

To help consumers evaluate and compare local hospital performance specific to specialty service lines and specialty focus areas, Healthgrades analyzed and identified the top ranked hospitals in each state across 8 key specialty areas for 2022: Joint Replacement, Spine Surgery, Cardiac Surgery, Coronary Interventional Procedures, Stroke Care, Critical Care, Pulmonary Care, and Prostate Surgery. This analysis, rooted in clinical performance, builds on the 2022 Healthgrades Specialty Excellence Awards Methodology.

To measure performance, Healthgrades used Medicare inpatient data from the Medicare Provider Analysis and Review (MedPAR) file purchased from the Centers for Medicare and Medicaid Services (CMS) for years 2018 through 2020.

Patient outcomes data for 16 conditions or procedures were analyzed (see list below) for virtually every hospital in the country. Hospital performance in these 16 conditions form the base of the final Specialty Excellence Award and State Ranking results (See Appendix 1: Specialty Award Categories and Requirements for a list for each area.)

Mortality-Based Procedures & Conditions

Chronic Obstructive Pulmonary Disease (COPD) Pneumonia
Coronary Artery Bypass Graft (CABG) SurgeryRespiratory Failure
Coronary Interventional ProceduresSepsis
StrokeValve Surgery
Pulmonary Embolism

In-Hospital Complications-Based Procedures & Conditions

Total Hip ReplacementBack and Neck Surgeries (Without Spinal Fusion)
Prostate Removal SurgerySpinal Fusion
Diabetic EmergenciesTotal Knee Replacement
Transurethral Prostate Resection Surgery 

Using Star Ratings to Communicate Performance

The first and most fundamental way that Healthgrades communicates performance is 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. For more details, see the Healthgrades Mortality and Complications Outcomes 2022 Methodology.

The purpose of risk adjustment is to obtain fair statistical comparisons of mortality and complication rates between hospitals while accounting for differences in underlying risk factors observed in the data among disparate populations or groups.

Significant differences in clinical and demographic risk factors are found among patients treated in different hospitals. Therefore, it is necessary to make accurate and valid comparisons of clinical outcomes with a methodology using risk-adjustment techniques. Risk factors may include age, sex, specific procedure performed, and comorbid conditions (e.g., hypertension, chronic heart failure, and diabetes).

Developing the Healthgrades hospital star performance categories involves four steps:

  1. The hospital predicted value (predicted number of deaths or complications at each hospital) is calculated by summing the individual patient record predicted values determined from logistic regression models discussed above. 
  2. The hospital predicted value is compared with the actual or observed value (e.g., 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. This test is performed to make sure that differences were very unlikely to be caused by chance alone. A z-score is used to establish a 90% confidence interval.
  4. Hospital performance categories are determined based upon the outcome of the test for statistical significance.

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.

Healthgrades uses z-scores (individual or aggregate) to determine performance. A z-score is a standardized statistical test that calculates the difference between the actual and predicted complication and mortality rates, taking into account patient variability and volume. A higher z-score means better performance.

A complete description of the methodology including risk factors, multivariate logistic regression model, and other relevant information is available in the Healthgrades Mortality and Complications Outcomes 2022 Methodology. A full list of ICD-10 codes used to define each model can be found in Healthgrades ICD-10 Mapping Tool at https://icd10mappingtool.healthgrades.com/.

Using State Rankings to Communicate Performance

Another way Healthgrades communicates information on hospital performance is with State Rankings and Specialty Excellence Awards, helping patients more easily identify top performers. Rankings and Awards determine and communicate a hospital’s superior performance when compared to other eligible hospitals.

Specifically for State Rankings, each Ranking has eligibility requirements specific to the nature and intent of the achievement and is aligned with requirements for Specialty Excellence Awards (See Appendix 1). State Rankings may reference a singular cohort (e.g. Stroke Care) or require the combination of a grouping of cohorts (e.g. Critical Care). Healthgrades will issue state rankings for the Top 3 or Top 5 performers, across 8 specialty areas, following the Ranking Determination & State Eligibility Requirements outlined below. Specific information regarding the cohorts included is outlined in the Specialty Award Categories and Requirements in Appendix 1.

State Ranking Determination & State Eligibility Requirements

For each hospital, Healthgrades assigns an overall score for each specialty area based on hospital performance as determined by a single z-score or average of volume-weighted z-scores when more than one condition or procedure is included in the award. (See Appendix 1: Specialty Award Categories and Requirements for a list for each award.) The strength of a hospital's single z-score or average of volume-weighted z-scores when more than one condition or procedure is included in the award, is a key driver in ranking determination. Additionally, hospital eligibility for State Ranking awards requires a hospital receive a rating in the cohort(s) included in the determination of the award, no 1-Star ratings in the cohort(s) included in the determination of the award, and at least one 5-Star rating in a cohort included in the determination of the award.

For a state to be eligible to have hospitals rankings, either in the Top 3 or Top 5, there need to be substantive count of hospitals eligible in each state for the individual award area. States with 6 or fewer hospitals that meet the requirements in an individual award area are NOT eligible for rankings in that area. When a state has between 7 and 10 eligible facilities (inclusive) for an individual award area, the top 3 facilities (ranked by z-score and following the Ranking Determination criteria) will be named the Top 3 Facilities (#1, #2, #3) in the state for that award area. When a state has 11 or more eligible facilities for an individual award area, the top 5 facilities (ranked by z-score and following the Ranking Determination criteria) will be named the Top 5 Facilities (#1, #2, #3, #4, #5) in the state for that award.

Appendix 1

Specialty Award Categories and Requirements

The following sections provide a list of conditions, procedures, and analyses that are included for each Specialty Excellence Award.

Cardiac Surgery

The Cardiac Surgery specialty award recognizes hospitals with superior clinical outcomes in heart bypass surgery and heart valve surgery.

The Cardiac Surgery specialty award is based on:

  • Coronary Artery Bypass Graft (CABG) Surgery
  • Valve Surgery

To be considered for an award in this specialty area, a hospital must be evaluated in both of the above procedures based on MedPAR data. The Cardiac Surgery award is determined by the volume-weighted average of coronary artery bypass graft (CABG) surgery and valve surgery z-scores. The z-scores for in-hospital mortality and in-hospital + 30-day mortality are used in these calculations. The in-hospital + 30-day mortality outcome receives 60% of the weight in the calculations and in-hospital mortality receives 40% of the weight.

Coronary Intervention

The Coronary Intervention specialty award recognizes hospitals with superior clinical outcomes in coronary intervention procedures including angioplasty with stent.

The Coronary Intervention specialty award is based on one cohort: coronary interventional procedures (angioplasty/stent). The Coronary Intervention award is based on the average of in-hospital mortality and in-hospital + 30-day mortality z-scores based on MedPAR data. The in-hospital + 30-day mortality outcome receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight.

Critical Care

The Critical Care specialty award recognizes hospitals with superior clinical outcomes in treating pulmonary embolism, respiratory failure, sepsis, and diabetic emergencies.

The Critical Care specialty award is based on:

  • Diabetic Emergencies 
  • Pulmonary Embolism  
  • Respiratory Failure 
  • Sepsis 

To be considered for an award in this specialty area, a hospital must be evaluated in at least three out of four of the conditions listed above based on MedPAR data. Healthgrades calculates the average z-scores for sepsis, pulmonary embolism, and respiratory failure using in-hospital mortality and in-hospital + 30-day mortality. The in-hospital + 30-day mortality receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight. Healthgrades also calculates the average z-scores for diabetic emergencies using in-hospital complications. The Critical Care award is based on a volume-weighted average of these average z-scores.

Joint Replacement

The Joint Replacement specialty award recognizes hospitals with superior clinical outcomes in total knee and hip replacement.

The Joint Replacement specialty award is based on:

  • Total Hip Replacement 
  • Total Knee Replacement 

To be considered for an award in this specialty area, a hospital must be evaluated and categorized into one of three performance categories for both total knee replacement and total hip replacement. We evaluate both procedures based on in-hospital complications. The Joint Replacement award is based on a volume-weighted average of the z-scores for these procedures.

Prostate Surgery

The Prostate Surgery specialty award recognizes hospitals with superior clinical outcomes in prostate removal surgery and transurethral resection of the prostate (TURP).

The Prostate Surgery specialty award is based on:

  • Prostate Removal Surgery
  • Transurethral Prostate Resection Surgery

To be considered for an award in this specialty area, a hospital must be evaluated for either one or both conditions based on MedPAR data. We evaluate both procedures based on in-hospital complications. The Prostate Surgery award is based on the volume-weighted average of the z-scores for these procedures or the direct z-score if only one type of procedure is performed.

Pulmonary Care

The Pulmonary Care specialty award recognizes hospitals with superior clinical outcomes in treating chronic obstructive pulmonary disease (COPD) and pneumonia.

The Pulmonary Care specialty award is based on:

  • Chronic Obstructive Pulmonary Disease (COPD)
  • Pneumonia

To be considered for an award in this specialty area, a hospital must be evaluated in both conditions based on MedPAR data. We first calculate the average z-scores for these conditions using in-hospital mortality and in-hospital + 30-day mortality. The in-hospital + 30-day mortality receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight. The Pulmonary Care award is based on a volume-weighted average of these average z-scores.

Spine Surgery

The Spine Surgery specialty award recognizes hospitals with superior clinical outcomes in back and neck surgeries and spinal fusion.

The Spine Surgery specialty award is based on:

  • Back and Neck Surgeries (Without Spinal Fusion)
  • Spinal Fusion

To be considered for an award in this specialty area, a hospital must be evaluated in both procedures based on MedPAR data. We evaluate both procedures based on in-hospital complications. The Spine Surgery award is the volume-weighted average of these z-scores for these procedures.

Stroke Care

The Stroke Care specialty award recognizes hospitals with superior clinical outcomes in the care and treatment of stroke.

The Stroke Care specialty award is based on one condition: stroke. To be evaluated, a hospital must have a transfer-out rate of less than 10% for the three years of data used. The Stroke Care award is based on the average z-scores for in-hospital mortality and in-hospital + 30-day mortality. The in-hospital + 30-day mortality receives 60% of the weight in this calculation and in-hospital mortality receives 40% of the weight.

Click here for a full PDF of the Specialty State Rankings Methodology

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