FAQ: How and why we rank and rate hospitals

FAQ: 2018-19 Best Hospitals Specialty Rankings

FAQ: 2018-19 Best Hospitals Procedure and Condition Ratings

FAQ: 2018-19 Best Hospitals Honor Roll

FAQ: 2018-19 Best Regional Hospitals

FAQ: 2018-19 Best Children’s Hospitals

2018-19 Best Hospitals Specialty Rankings

Published August 14, 2018

You’ve been informed by your doctor that you’re about to take your place in the parade of roughly 33 million patients a year who are admitted to U.S. hospitals for a procedure or other care. The hospital the doctor suggested for you might be just right for you, but maybe not. Checking the U.S. News Best Hospitals specialty rankings in whichever of the 16 specialties applies to you is in order if your care calls for special expertise or if age, physical ailments or a chronic condition could add a layer of risk. This FAQ explains how the Best Hospitals specialty rankings are produced and addresses questions of interest to media and health care professionals. A formal methodology report, available as a downloadable PDF, provides much more detail.

What are the specialties in which hospitals are ranked?

There are 16 specialty areas. In 12, ranking is determined mostly by data: cancer, cardiology & heart surgery, diabetes & endocrinology, ear, nose & throat, gastroenterology & GI surgery, geriatrics, gynecology, nephrology, neurology & neurosurgery, orthopedics, pulmonology, and urology.

In the remaining four specialties (ophthalmology, psychiatry, rehabilitation and rheumatology), ranking is determined entirely by reputation, based on responses from three years of surveys of physician specialists.

The rankings name the top 50 hospitals for complex care in each of the 12 data-driven specialties and roughly a dozen in the four reputation-determined specialties.

Why does U.S. News rank hospitals?

U.S. News estimates that nearly 2 million hospital inpatients a year face the prospect of surgery or special care that poses either unusual technical challenges or significantly heightened risk of death or harm because of age, physical condition or existing conditions. The rankings are a tool that can help such patients find sources of especially skilled inpatient care.

Who might be a patient like this?

Someone in his 80s or 90s with pancreatic cancer would be one of many examples. Most hospitals would reject him as a patient — as indeed they should if their surgeons lack the expertise to remove the cancer without harming the rest of the fragile pancreas. But multiple investigations by U.S. News have found that some hospitals without the requisite skills would go ahead, possibly at considerable risk. He would be better served by one of the hospitals in the Best Hospitals cancer rankings, many of which see a steady stream of patients like him.

How are the rankings organized and updated?

The 16 Best Hospitals national specialty rankings are updated annually. As noted, rankings in 12 of the 16 rely largely on objective data. Each specialty showcases the 50 top-scoring hospitals, based mostly on death rates for particularly challenging patients, on patient safety and on other measures of performance that can be assessed using hard data. All evaluated hospitals and their results and overall scores are displayed online, but rankings are only displayed for the top 50. Hospitals below the top 50 are ordered alphabetically.

In these 12 specialties, results from the three most recent years of an annual reputational survey of specialized physicians are also factored in. Surveyed physicians are asked to name up to five hospitals they consider the best for difficult cases in their specialty.

Hospitals that are not nationally ranked but scored high enough in a specialty to put them in the top 10 percent of the analyzed centers are recognized as high performing. Hospitals that are nationally ranked in at least one of the 12 data-determined specialties, or that earned at least three ratings of high performing across the 12 specialties and nine Best Hospitals procedures and conditions, are further designated as Best Regional Hospitals within their state, metro area or other region, subject to the criteria described below.

In the four Best Hospitals reputational specialties, national ranking is based on the latest three annual physician surveys referenced above. Those receiving nominations from an average of at least 5 percent of the respondents are nationally ranked Best Hospitals. Those nominated by at least 3 percent but below 5 percent of physicians are high performing.

The 20 hospitals with the most and highest rankings and the greatest number of high performing procedure and condition ratings are recognized in the Honor Roll.

Are the highest-ranking hospitals always the best choices?

Not necessarily. Hospitals are evaluated across a wide range of conditions and procedures. Within that range, hospitals can and do perform differently. In pulmonology, for example, a hospital might rank below another one but do better at treating patients with chronic obstructive pulmonary disease.

So the rankings should just be a starting point?

That’s right. Patients still have to do their own research and talk with their doctors. We also understand that families have to consider such factors as the stress and expense of travel and lodging in another city and their insurer’s willingness to pay for care if a hospital is out of network.

How many hospitals were analyzed for the 2018-19 rankings?

For consideration in the 12 data-driven rankings, the 2018-19 rankings started with 4,65 6 hospitals, which represent virtually all U.S. community inpatient facilities.

Are only teaching hospitals eligible for the rankings?

No. That misconception persists, even in articles in medical journals that make the assertion, which has never been true. Teaching status or medical-school affiliation are only two of the four ways in which a hospital can be a rankings candidate. Many hospitals become part of the eligible pool through the two other pathways.

In the 2018-19 rankings, a hospital qualified for consideration in the data-driven specialties if it satisfied any of four criteria: 1) it was a teaching hospital, or 2) it was affiliated with a medical school, or 3) it had at least 200 beds set up and staffed, or 4) it had at least 100 beds and offers at least four out of eight advanced technologies associated with high-quality care, such as a PET/CT scanner and certain precision radiation therapies. This year, 2,2 64 hospitals, just under half of the total number in the initial pool, met one of the four standards.

In the four specialties in which ranking was determined only through the physician survey, any hospital with enough nominations over the last three surveys was ranked.

Does U.S. News evaluate and rank VA and military hospitals?

No. We would very much like to evaluate these important centers, but repeated efforts over more than 25 years to persuade the federal government to release performance data have been to no avail.

What followed after determining initial eligibility?

Hospitals had to show that they treated a given number of patients who had specifically defined conditions or procedures. The threshold number, which varied by specialty, was based on traditional fee-for-service Medicare inpatients who were discharged during the three years from 2014 to 2016. Because the rankings focus on challenging care, only patients who had particular procedures or conditions at a defined level of severity and complexity were included. The minimum in cardiology & heart surgery, for example, was 1,3 91 patients, 500 of whom had to be surgical. In orthopedics the minimum was 302 patients, 275 of them surgical.

A hospital that fell short was still evaluated if it was nominated by at least 1 percent of the physicians in a specialty who responded to the 201 6 , 201 7 and 201 8 reputational surveys.

A total of 1,89 7 hospitals met these standards and qualified for further consideration in at least one specialty.

How many hospitals were ranked?

Across all 16 specialties, only 15 8 U.S. hospitals performed well enough to be nationally ranked in one or more specialties.

What determined whether a hospital would be ranked?

We evaluated each hospital’s performance using a variety of measures. Some data came from the federal Centers for Medicare & Medicaid Services’ Standard Analytical File database. Other information came from the American Hospital Association and from professional organizations. We put the heaviest reliance on outcomes because of the self-evident connection between a patient’s survival chances and the quality and safety of their care. Other data, such as the number of patients and the ratio of nurses and patients, are less obviously related to quality and safety, but ample research supports the connection. The physician survey also played a role, although it accounted for only slightly more than one-fourth of each hospital’s score (more on that below).

In the four reputational specialties, most care is delivered on an outpatient basis. The number of outpatients who die in these specialties is so low that risk-adjusted mortality rates, heavily weighted in the 12 other specialties, mean little. Hospitals in these specialties are therefore ranked solely on reputation.

How were the different factors combined?

Each hospital analyzed in the 12 data-driven rankings received an overall score from 0 to 100 based on four elements: survival, patient safety, care-related factors such as the intensity of nurse staffing and the breadth of patient services, and expert opinion obtained through the physician survey. The hospitals with the 50 highest scores in each specialty were ranked. Scores and data for all eligible hospitals in each specialty are also posted. The four elements and their weightings, in brief:

Survival (37.5 percent). A hospital’s success at keeping patients alive was judged by comparing the number of Medicare inpatients with certain conditions who died within 30 days of admission in 2014, 2015 and 2016 with the number who would be expected to die given the severity of illness. Hospitals were scored from 1 to 10, with 10 indicating the highest survival rate relative to other hospitals and 1 the lowest rate. Widely used research software (3M Health Information Systems Medicare Severity Grouper) took each patient’s condition into account.

Patient safety (5 percent). This score reflects a hospital’s success in preventing four harmful types of medical errors or oversights, such as injuries caused during surgery. Two of these types of “patient safety indicators,” defined by the federal Agency for Healthcare Research and Quality, were dropped this year because of their rarity. Hospital performance in the four individual PSIs is displayed online from 1 to 3 on a three-point scale, and the overall Patient Safety Score is displayed from 1 to 9.

Other care-related indicators (30 percent). These include nurse staffing, patient volume, certain clinically proven technologies and other measures related to quality of care. The 2016 American Hospital Association Annual Survey was the primary source.

Expert opinion (27.5 percent). Each year, board-certified physicians in the 16 Best Hospitals specialties are invited to list up to five hospitals, ignoring location and cost, that they consider to be the best in their area of expertise for complex or difficult cases. The figures displayed in the rankings represent the average percentages of responding specialists in 2016, 2017 and 2018 who named the hospitals. More than 21,000 physicians responded in 2018. In one specialty, cardiology & heart surgery, expert opinion receives a weight of 24.5 percent, with 3 percent weight determined by the extent to which a hospital is publicly transparent about certain heart-care-related performance metrics.

Doesn’t reputation still determine which hospitals are ranked?

No. Many ranked hospitals have very low, even zero, reputational scores but are strong clinical performers. In the 2018-19 orthopedics rankings, to take this specialty as one of many examples, 28 ranked hospitals had reputational scores below 2 percent.

How are hospitals ranked in the four specialties without objective data?

In the four reputationally determined specialties, ranked hospitals had to be cited by an average of at least 5 percent of the physicians who responded to the latest three years of U.S. News surveys of specialists. That resulted in lists of 1 1 hospitals in psychiatry, 1 2 in ophthalmology and 1 3 each in rehabilitation and rheumatology.

What methodology changes were made in the 2018-19 rankings?

The most significant change was that patients who were transferred from one hospital to another were excluded from the calculation of risk-adjusted survival. In prior years, such patients had been excluded in most circumstances, but were included as an adjustment made to the survival score of hospitals that received particularly high proportions of transfer cases.

How does U.S. News decide what changes to make to its methodology?

Each year RTI International and U.S. News revisit the methodology based on the medical literature and input from hospitals and health care experts. U.S. News approves all methodology changes.

What is the Honor Roll?

The Best Hospitals Honor Roll recognizes 20 hospitals with unusual competence across a range of adult specialties, procedures and conditions. It takes into account the full range of adult inpatient care — both performance in the Best Hospitals specialty rankings and in the Best Hospitals procedures and conditions. See the Honor Roll section for more information.

Where can more detailed information about the Best Hospitals methodology be found?

A complete description of the data analysis, the 201 8 -1 9 Best Hospitals Methodology Report, is available as a viewable and downloadable PDF.

2018-19 Best Hospitals Honor Roll

Published August 14, 2018

The Best Hospitals Honor Roll is a ranked list of 20 hospitals that excelled in the 16 Best Hospitals specialties and nine procedures and conditions ratings. For the first 26 years of Best Hospitals, the Honor Roll recognized exceptional performance in specialized, high-complexity inpatient care. In the 2016-17 ranking, it evolved to reflect safe, efficient and appropriate delivery of care of all kinds, from birth to the end of life.

How does the Honor Roll work?

The Honor Roll factors in hospital performance in the 16 Best Hospitals specialty rankings and in the nine Best Hospitals procedures and conditions ratings.

Hospitals were awarded points by being nationally ranked in the 12 Best Hospitals specialty rankings, driven primarily by hard data* or in the four reputational specialty rankings** or by being rated as high performing in the nine procedures and conditions***.

* Cancer, cardiology & heart surgery, diabetes & endocrinology, ear, nose & throat, gastroenterology & GI surgery, geriatrics, gynecology, nephrology, neurology & neurosurgery, orthopedics, pulmonology, and urology. ** Ophthalmology, psychiatry, rehabiliation, and rheumatology.
*** Colon cancer surgery, lung cancer surgery, abdominal aortic aneurysm repair, aortic valve surgery, heart bypass surgery, hip replacement, knee replacement, congestive heart failure and chronic obstructive pulmonary disease.

How were points awarded?

In the 12 data-driven specialties, all 50 ranked hospitals received points. The No. 1-ranked hospital received 25 Honor Roll points, No. 2 received 24 points and so on. All hospitals ranked 21 through 50 received 5 points. The maximum number of points across all 12 specialties is therefore 300, but no hospital was or has ever been No. 1 in all 12 specialties.

In the four Best Hospitals specialty rankings based entirely on reputation (ranked hospitals were recommended by at least 5 percent of respondents to annual U.S. News physician surveys), the number of ranked hospitals varies year by year and specialty by specialty. The No. 1-ranked hospital received 10 Honor Roll points, No. 2 received 9 points and so on; all hospitals ranked from 10 to the final ranked hospital received 1 point. If a hospital had ranked at the top in all four reputational specialties (none was), it would have received 40 points.

In the nine Best Hospitals procedures and conditions ratings, hospitals received 12 Honor Roll points for each “high performing” rating. Hospitals that achieved a rating of high performing in all nine procedures and conditions, as 29 did, received 108 points.

The 20 hospitals that earned the most points out of the 448 possible comprised the 2018-19 Honor Roll.

2018-19 Best Hospitals Procedures and Conditions Ratings

Published August 14, 2018

U.S. hospitals will admit an estimated 33 million patients in the next 12 months. More than 1 million will have a knee or hip replaced and about 400,000 will undergo heart bypass surgery. Heart failure will account for about 900,000, the respiratory condition called COPD another 700,000 and surgery to remove all or part of the colon some 250,000.

Any hospital should be able to treat such relatively common ailments successfully, and many do — but not all. The Best Hospitals procedures and conditions ratings show consumers how well their local hospitals stand up to close scrutiny in those six procedures and conditions and three others. How U.S. News evaluated hospitals for the ratings is addressed in this FAQ. A comprehensive methodology report is available as a downloadable PDF.

What are the Best Hospitals for procedures and conditions ratings?

The Best Hospitals procedures and conditions ratings — originally called Best Hospitals for Common Care — evaluate almost every hospital in the U.S. that admits patients in any of nine common procedures and conditions: colon cancer surgery, lung cancer surgery, heart bypass surgery, aortic valve surgery, abdominal aortic aneurysm repair, hip replacement, knee replacement, heart failure and chronic obstructive pulmonary disease, or COPD. The list of procedures and conditions will expand over time.

How are the procedure and condition ratings different from the specialty rankings?

The Best Hospitals specialty rankings are meant for patients with life-threatening or rare conditions who need a hospital that excels in treating complex, high-acuity cases.

The Best Hospitals procedure and condition ratings focus on individual procedures and conditions like hip replacement and heart failure rather than on broader specialties like orthopedics and cardiology. The goal is to evaluate how well hospitals perform in each procedure or condition and not just with the most difficult cases, as with the specialty rankings, but with the full range of patients. The methodology is considerably different; hospital reputation with specialists, for example, does not play a role. Finally, the evaluations produce ratings, not numerical rankings. Hospitals that treated enough patients to be evaluated are rated high performing, average or below average in each procedure or condition.

Is there an Honor Roll?

There is no Honor Roll just for procedures and conditions. The Best Hospitals Honor Roll now takes both the national specialty rankings and the procedure and condition ratings into account, as described separately.

What data sources were used?

We analyzed objective data from multiple sources, including a federal data set known as the Standard Analytical File, which contains details of every hospital admission paid for by traditional Medicare. We used SAF data on inpatients age 65 and older who were treated from 2012-2016 to assess each hospital’s risk-adjusted rates of mortality, readmission and other outcomes. We also used a limited amount of data from late 2011.

In addition, our analysis incorporated publicly available data points from the Centers for Medicare & Medicaid Services, the agency that oversees Medicare. These included data on each hospital’s efforts to prevent dangerous blood clots and the results from federally mandated patient-satisfaction surveys.

Hospital reputation was not a factor in the ratings.

Our methodology also drew on several measures from the 2016 American Hospital Association‘s annual survey, one measure from the American Nurses Credentialing Center and two from the Society of Thoracic Surgeons. None of these organizations have endorsed or been asked to endorse the U.S. News ratings.

How were the ratings for each hospital determined?

We defined nine groups of patients, each corresponding to one of the common procedures or conditions being rated. For each group, we assessed each hospital’s risk-adjusted outcomes, such as 30-day mortality, 30 -day readmission and length of stay. We also factored in variables that have been linked to higher quality, including volume, nurse staffing and whether the hospital employed a specially trained physician known as an intensivist. In addition, patient satisfaction scores were factored into the ratings in most procedures.

A hospital’s stance on data transparency was also a factor. In our heart bypass surgery and aortic valve surgery ratings, we weighed whether the hospital had voluntarily released ratings it received from the Society of Thoracic Surgeons, a professional organization for heart and chest surgeons. For hospitals that had done so, we factored in their STS ratings as of February 1, 2018.

How many hospitals did U.S. News evaluate?

In 2018, U.S. News evaluated more than 4,500 hospitals to generate the procedure and condition ratings. While more than 1, 1 00 hospitals were rated high performing in at least one procedure or condition, only 29 were rated high performing in all nine procedures and conditions.

What do the ratings mean?

An overall rating of high performing indicates a hospital was significantly better than the national average in a given procedure or condition. Hospitals rated below average scored significantly below the national average. Hospitals rated average do not all have equal performance, but they were not distinctly different from average in our methodology. In each procedure and condition, 10 to 20 percent of the evaluated hospitals in a condition or procedure typically fell into the high performing tier and another 10 to 20 percent were rated below average.

Relatively few hospitals performed consistently across all measures for a given condition or procedure. Strengths and weaknesses in particular measures often varied considerably between hospitals with similar overall ratings. Such differences give patients flexibility by allowing them to decide, in consultation with their doctor, which qualities are most important to them. One hospital might have a lower readmission rate but have worse patient experience scores. Another might have a better balance of nurses to patients but relatively low numbers of patients.

How many hospitals earned a rating of high performing in a procedure or condition?

More than 1, 1 00 hospitals were rated high performing in at least one procedure or condition; 29 were rated high performing in all nine.

Should I worry about going to a hospital rated average or below average or that is unrated?

About 5 0 to 70 percent of the hospitals in each procedure or condition were rated average, so they could be considered typical. Some hospitals were rated below average in part because of low patient volume, not necessarily because of a high number of deaths or other adverse events. No firm conclusion can be reached about any unrated hospital; these hospitals did not treat enough patients to be evaluated fully. The ratings are just a starting point for patient decision-making, which certainly should include consulting a doctor.

Pending such consultation, patients who have access to a high performing or average hospital might elect to choose that hospital over one that is below average or unrated in the type of care they need.

Is there a list of the worst hospitals?

No. For each procedure and condition, hospitals are rated high performing, average and below average. The three-level approach gives patients a way to quickly compare the options available in their communities and then, based on their research and consultation with their doctors, to choose an appropriate hospital.

Why weren’t patients younger than 65 included?

The data sets we analyze do not include typical patients under 65, since they contain records only of Medicare patients. “All-payer” data covering younger patients, unfortunately, are not available for most hospitals. This is not necessarily a significant omission, however. How well older patients are treated is generally considered a good test of a hospital’s capabilities. Such patients have a greater chance of being admitted with one or more conditions that put them in a higher-risk category, such as diabetes or high blood pressure. The condition for which they were admitted also is likely to be more advanced than in younger patients.

How reliable are the data?

Claims data from the Medicare database are the best available source. We are open to exploring alternatives for future editions of the ratings. Risk-adjusted data from clinical registries are one promising area.

How did U.S. News build in risk adjustment?

We took a number of risk factors into account: ? Age at admission.
? Sex.
? Transfer status. A patient transfer from the initial receiving hospital may indicate a complex procedure or condition. Patients were classified as inbound transfers if they were treated at another acute-care hospital on the day of admission, if claims data indicated they were transferred or if a previous claim indicated an outbound transfer.
? Year of hospital admission. Quality of care tends to improve over time. This means the risk of adverse outcomes is less year to year. For that reason, year of admission is included as a risk factor.
? Comorbidities. A wide range of comorbidities such as diabetes is associated with higher death rates. We used an inventory known as the Elixhauser comorbidities in risk adjustment.
? Medicare eligibility status. The reason or reasons why the patient is eligible for Medicare: age, disability or end-stage renal failure. This is a proxy for comorbidities.
? Socioeconomic status. Patients with lower incomes and education are typically sicker when they arrive at the hospital and may face more challenges in obtaining or managing their care after they are discharged. This can affect their risk of death, readmission and complications. When hospitals differ by the socioeconomic status of their patients, this can create bias in comparing outcomes. We used “dual eligibility” — patients who are eligible for both Medicare and Medicaid — as a socioeconomic factor.

Why did U.S. News adjust for socioeconomic status?

In 2014, the National Quality Forum, an influential standard-setting body, recommended considering socioeconomic status in certain evaluations of hospital performance. Since our objective is to enable a patient who is consulting our ratings to make apples-to-apples comparisons among hospitals, it follows that we should adjust for patient attributes such as age, sex and socioeconomic status.

Did U.S. News consider patient satisfaction?

The methodology uses one measure, how discharged patients rated a hospital overall, from the federal government’s quarterly survey called Hospital Consumer Assessment of Health Providers and Systems, or HCAHPS. Summary results in seven topic areas are displayed but were not part of the methodology. They relate to nurses’ and doctors’ communication skills, staff responsiveness, pain management, medication harm, discharge information and help in engaging patients in their recovery.

What changes were made from last year?

We made several methodology changes, including:

— We added outcome measures, including surgical-site infection prevention (added in abdominal aortic aneurysm repair, aortic valve surgery and heart bypass surgery), readmission prevention (in colon cancer surgery and lung cancer surgery) and prevention of prolonged hospitalization (in lung cancer surgery).

— We removed Nurse Magnet recognition as a quality indicator from six of nine cohorts.

— A measure of patient experience, derived from the widely used HCAHPS survey, was added in AAA repair, aortic valve surgery, heart bypass surgery and lung cancer surgery.

— We added a measure based on the rate of donor blood transfusions in hip replacement and knee replacement.

— We added flu immunization rates in heart failure and COPD.

— We refined several of our risk models for outcome measures, for example, by adjusting for certain procedure types in calculating lung cancer surgery outcomes.

How do the U.S. News ratings compare with other public reporting on hospital quality?

In judging the validity and usefulness of any public reporting effort to evaluate health facilities, patients should ask: What is its intention? What information does it claim to deliver? Does it meet the stated intent? The national Best Hospitals and Best Children’s Hospitals rankings, for example, are meant to be used as guidance when life is in the balance or an uncommon condition or procedure is involved. Most patients, thankfully, will not need to consult them.

Best Hospitals for procedures and conditions, on the other hand, rates overall quality of inpatient care in the kinds of procedures and conditions that many hospitals commonly encounter. Clinical outcomes (such as mortality, readmissions and length of stay) are stressed, but among the other measures included are patient volume, patient satisfaction and hospital staffing data. Patients can choose to factor some or all of these individual quality indicators into their decisions about where to get care. For comparison, other public reporting approaches measure different aspects of hospital quality and/or use different approaches to assess quality:

— The federal government’s Hospital Compare website publishes an array of quality data as well as hospital star ratings.

— The Joint Commission measures how frequently each hospital follows specific guidelines. It doesn’t use any outcome measures.

— The Leapfrog Group grades hospitals from A to F on patient safety.

— Consumer Reports has scored hospitals from 0 to 100 on patient safety.

— Healthgrades rates hospitals in a variety of clinical areas, using mortality, complication rates and patient experience ratings.

2018-19 Best Regional Hospitals

Published August 14, 2018

U.S. News first published Best Regional Hospitals in 2011. These state and metro area rankings offer information on community hospitals that are highly rated but may not be nationally ranked. Regional rankings are displayed for every state and for 51 metro areas with a population of 1 million or more in the 2010 census, provided there are at least two Best Regional Hospitals. In 201 8 -1 9 , 5 20 hospitals were recognized as Best Regional Hospitals. Several states had no Best Regional Hospitals. There is no separate methodology report for the regional rankings.

What defined a 2018-19 Best Regional Hospital?

A Best Regional Hospital is a hospital that offers a full range of services (as opposed to a specialty hospital) and that either was nationally ranked in one of the 12 data-driven Best Hospitals specialties or had three or more ratings of high performing in a specialty or in the nine Best Hospitals procedures and conditions.

How was each Best Regional Hospital assigned its numerical ranking?

In a given region (state or major metro area), a hospital on the Best Hospitals Honor Roll outranked all other hospitals that were not on the Honor Roll regardless of point totals. Other hospitals located in each region were ranked according to the number of points they earned: Hospitals earned two points for each of the 12 data-driven Best Hospitals specialties in which they were nationally ranked and one point for each of the 12 specialties and nine procedures and conditions in which they were rated high performing. In addition, they lost one point for each procedure or condition in which they were rated below average.

Can a specialty hospital, such as an orthopedic, cancer or children’s hospital, be recognized as a Best Regional Hospital if it is nationally ranked or high performing?

No. The primary intent of the designation is to identify hospitals that perform well across a range of specialties, conditions and procedures. A specialty hospital’s profile and its ratings and rankings pages do show the area or areas of care in which it is ranked or high performing.

In which metropolitan areas and states were hospitals ranked?

Best Regional Hospitals rankings were published in all 51 metropolitan areas with a population of 1 million or more in the 2010 Census and in every state, provided that the state or metro area had at least two Best Regional Hospitals. In all, hospitals were ranked in 4 9 metro areas.

U.S. News departed from the U.S. Census Bureau list of Metropolitan Statistical Areas in three cases by using larger Combined Statistical Areas to include nearby smaller cities with nationally ranked hospitals. The three CSAs are Detroit (by adding Ann Arbor); Raleigh-Cary, North Carolina (adding Durham and Chapel Hill and renaming the expanded area Raleigh-Durham); and Salt Lake City (adding Ogden).

Some metropolitan areas, such as Cincinnati and New York, cross state lines. That is also true for Washington, D.C., which was included as a metro area but not a state.

Rankings were not published for U.S. territories.

What about hospitals in smaller metro areas or outside metro areas?

U.S. News has grouped counties and county equivalents like parishes into approximately 200 regions that reflect geography, local custom and regional health care markets. High performers were recognized but not numerically ranked in regions that are not major metro areas.

Can I find out what cities and towns are included in a region?

Yes. Email your request to health-pr@usnews.com.

Is there a listing of all of the Best Regional Hospitals in a particular region?

To see all Best Regional Hospitals in a state, enter the state name in a search or go to Best Regional Hospitals by area. One more click will take users to a list of all Best Regional Hospitals for any U.S. News-recognized region within that state.

Why weren’t children’s hospitals ranked in metro areas?

Very few metro areas have more than one or two Best Children’s Hospitals. That makes decisions about where to go for expert pediatric care simpler than for adult care; ranking small numbers of children’s hospitals within a metro area wouldn’t offer meaningful assistance. A Best Children’s Hospitals FAQ is available below.

2018-19 Best Children’s Hospitals

Published June 26, 2018

What is the purpose of the Best Children’s Hospitals rankings? When should they be consulted? How are they determined? The following FAQ addresses these and other Best Children’s Hospitals questions. A fully detailed methodology report is available as a downloadable PDF.

Why does U.S. News rank children’s hospitals?

Relatively few children, compared with the number of adults, face life-threatening or rare conditions or have to go through complicated operations. But a child who does needs a caliber of expertise that a typical hospital, where nearly all inpatients are adults, simply cannot provide. Even a hospital with a busy maternity unit may not be equipped to deal with a newborn who weighs just a few pounds or requires surgery for a defective heart. Similarly, most hospitals don’t see large numbers of children with a range of cancers, respiratory illnesses or kidney conditions. Even among children’s hospitals and large pediatric services that do, the reality, as true in pediatrics as it is in adult care, is that some hospitals are better than others. That is why in 2006, U.S. News began collecting data that would allow ranking of pediatric centers on their ability to help children who need it the most.

How are the rankings organized and updated?

The 50 best-performing hospitals are ranked in each of 10 pediatric specialties. Unranked hospitals that provided enough information to be scored in a specialty are listed with their data but without rank or score. The rankings are updated annually in June. The Best Children’s Hospitals Honor Roll recognizes the 10 hospitals that received the highest number of points, based on the number of specialties in which they are ranked and how high they ranked in each one.

What are the 10 specialties?

Cancer, cardiology & heart surgery, diabetes & endocrinology, gastroenterology & gastrointestinal surgery, neonatology, nephrology, neurology & neurosurgery, orthopedics, pulmonology, and urology.

Are high-ranked hospitals always better choices?

No. Within a specialty, hospital performance is judged across a variety of conditions and procedures. So one hospital might outperform another in some of them, but the second might do better in others. In the pediatric orthopedic rankings, for example, one hospital might have an especially busy spina bifida clinic but doesn’t treat complex fractures as efficiently as another hospital might.

So the rankings should just be a starting point?

Exactly. Families have to weigh many considerations when they seek care for a child, including the stress and expense of traveling to another city with a sick child and staying for days or possibly weeks, as well as an insurer’s willingness to pay for care at a hospital outside its approved network.

How many hospitals were evaluated for these rankings?

For the 2018-19 rankings, U.S. News requested medical data and other information from 189 facilities. Of those, 118 — five more than last year — turned in enough data to be evaluated in at least one specialty, and 86 were ranked in one or more.

There’s so much information on usnews.com about each hospital. What should I focus on?

We do display quite a lot of information. All of it plays a part in determining how well a hospital delivers specialty care. Parents and caregivers have to decide for themselves which of all of these factors they want to weigh more or less heavily. Kids and families are all different. There’s no one-size-fits-all.

What’s a quick take on how each hospital is evaluated?

A third of each hospital’s score, or 33.3 percent, was tied to outcomes such as survival, infections and surgical complications. (In cardiology & heart surgery, outcomes counted for 38.3 percent because more and better data are available.) A hospital’s reputation, based on an annual survey of pediatric specialists and subspecialists in each of the 10 specialties, made up another 15 percent (8.5 percent in cardiology & heart surgery). The remaining portion of slightly more than 50 percent evaluated commitment to patient safety (such as the number of specific ways infections are minimized), excellence (such as the number of fellowship programs) and family centeredness (such as the degree to which families are involved in their children’s care).

Why does U.S. News include hospital reputation?

Experts’ opinions are capable of reflecting important information that isn’t evident in objective measurements. That’s particularly the case in a field as full of nuance and complexity as is the medical care of very sick children. We feel the opinions of pediatric specialists add to the objective measures that form the basis for the rankings.

How are the rankings organized?

In each of the 10 specialty areas, the 50 hospitals with the highest scores are ranked numerically. Many of the measures that went into hospital scores, such as nurse-to-patient ratios, are common to all specialties. Others, such as accreditation for bone marrow transplant, apply to just one or two specialties.

In addition to displaying performance information for the 50 ranked hospitals in each specialty, the same information is shown for unranked hospitals, less rank or score, if they provided enough data through the clinical survey to be evaluated. The unranked hospitals are listed alphabetically.

What is the significance of the Honor Roll?

The Best Children’s Hospitals Honor Roll recognizes 10 hospitals that are unusually competent not just in one or two specialties but in many.

How is the Honor Roll determined?

Hospitals received points for being ranked in a specialty, and the 10 hospitals with the most points across the 10 specialties make up the Honor Roll. The first-ranked hospital in a specialty received 25 points, the second-ranked hospital received 24 points and so on, until reaching No. 21. All hospitals ranked 21 through 50 received five points. If multiple hospitals had tied for the tenth-most points overall, the Honor Roll would have been extended.

How did U.S. News choose which children’s hospitals to evaluate?

Selection was originally determined by membership status in the National Association of Children’s Hospitals and Related Institutions, or NACHRI, now renamed the Children’s Hospital Association, or by nomination from teams of expert advisers. A hospital also can request to be considered. U.S. News makes such decisions not only on a hospital’s willingness to engage in public reporting but also on the size and scope of its pediatric program. Of approximately 200 hospitals U.S. News invites to participate in the survey each year, about a quarter of the hospitals are freestanding pediatric-focused facilities. Most of the others are pediatric departments within larger full-service hospitals and are so large that the department functions almost like its own hospital within a hospital — with its own staff, operating rooms and support services.

Are there changes from last year?

Year to year, there are always changes — we constantly try to improve our methodology. Our approach is conservative, however, since any alterations in our analysis affect not only the new rankings but the ability to compare them with previous results.

For the 2018-19 analysis, U.S. News made these changes of note:

— In the cardiology & heart surgery rankings, for surgical procedures categorized in each of five tiers used in the Society of Thoracic Surgeons’ Congenital Heart Surgery Database, increased emphasis was given to risk-adjusted mortality rates as opposed to unadjusted mortality rates. Same as last year, adjusted mortality accounted for 20 percent of a hospital’s overall cardiology score, and the weight of all outcomes measures was 38.3 percent.

— In the neonatology rankings, a measure of hospital readmission following initial discharge was dropped because hospitals faced challenges capturing and consistently reporting these events. Also, a measure of bloodstream infections in neonatal intensive care units was based on data from the most recent 12-month period rather than a 36-month period used previously.

— In an effort to safeguard against data-reporting errors that can occur when hospitals respond to a complex survey, U.S. News and its data contractor this year performed additional data review and verification steps, including extensive communication with dozens of hospitals about key data points.

How does U.S. News decide what changes to make to the methodology?

RTI International, a large North Carolina-based research and consulting firm that created the Best Children’s Hospitals methodology in 2006 (and is the U.S. News contractor for the Best Hospitals rankings), works every year with experts organized into specialized task forces, called working groups, to revisit and update the methodology. U.S. News editors review proposed changes and must approve them before they take effect.

Why does U.S. News ask hospitals for data instead of using existing data sources?

We use existing data whenever we can. The lack of banks of critical data that can be tapped in order to evaluate children’s hospitals has been a huge challenge. There is no pediatric equivalent of the Medicare database U.S. News mines for mortality, safety and volume information to construct the annual Best Hospitals adult rankings. In 2006, when U.S. News began looking into the possibility of ranking pediatric centers, children’s hospitals had barely begun to develop standards for care-related quality data or how to best analyze the results. That is still largely the case, despite important progress pediatric researchers have made in certain areas of performance measurement.

So in 2006, U.S. News asked RTI to put together a clinical survey for children’s hospitals. Some questions, such as nursing data and the extent and success of programs that prevent infection, touch on all 10 specialties. Others, such as complication rates of kidney biopsies and five-year survival rates for several types of cancer, are specialty-specific. The 2018-19 clinical survey was updated with the help of 147 medical directors, department chairs, infection specialists and others in 12 working groups.

What analytical approach determines the rankings?

Whether and how high a hospital ranked depends on its showing in three health care-related areas: outcomes, process and structure. Each generally makes up one-third of a hospital’s score.

What defines outcomes, process and structure?

Outcomes. These data reflect a hospital’s ability to keep children alive, keep them safe from harm by protecting them from infections and surgical complications and improving quality of life of children with chronic conditions. For example, we evaluate survival from three types of childhood cancers, bloodstream infections caused by central line catheters and success in managing serious asthma cases.

Process. The intent of the U.S. News process measure is to evaluate how well and efficiently a hospital goes about the day-to-day business of delivering care. That is determined in part by compliance with widely endorsed “best practices,” such as regular morbidity and mortality conferences to explore unanticipated deaths or complications, and commitment to infection control, such as having certified infection preventionists on staff and tracking the correct use of antibiotics prior to surgery.

It is important to have such programs, but they must deliver. So 15 percent of a hospital’s score (8.5 percent in the cardiology & heart surgery rankings) relies on the opinions of pediatric specialists and subspecialists via an annual survey that asks them to name up to 10 hospitals in their specialty where they would send the sickest patients without taking location or expense into account. Responses are combined from the three latest surveys, meaning for the 2018-19 rankings, surveys conducted in 2016, 2017 and 2018. Nearly 11,000 physicians were surveyed in 2018 and more than 4,000 responded.

Structure. This category reflects resources that a hospital makes available to patients, like the number of nurses who care for patients. We collect information about 39 elements, many relevant to every specialty and others specific to just one. A few examples are availability of surgery for congenital heart defects or for liver transplants, specialized clinics for children with diabetes or kidney disease and services for families that ease the anxiety of a child’s hospital stay.

More from U.S. News

11 Items to Pack in Your Hospital Bag

6 Tips to Keep Diabetics Out of the Hospital

How to Be a Good Patient Wingman

FAQ: How and Why We Rank and Rate Hospitals originally appeared on usnews.com

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