Elective hip and knee replacements are a prime example. Many urban centers routinely do hundreds a year. At Sterling, the three-year total for Medicare inpatients from 2010 through 2012 was 29 hips and 52 knees. And while the death rate for these operations is about 1 in 1,000 nationally, Medicare data in the U.S. News analysis show that the relative risk of death for the hospital's elective knee replacement patients was 24 times the national average and three times the national average for hip replacement patients. "You can save your life by picking the right place," says Leah Binder, director of the Leapfrog Group, a consortium of major employers that emphasizes safety in measuring hospital performance.
The U.S. News analysis was conducted as part of a new set of hospital ratings, Best Hospitals for Common Care, to be launched Wednesday. The first set of ratings will evaluate hospital performance in caring for traditional Medicare fee-for-service patients, in five procedures: bypass surgery without valve repair or replacement, elective hip and knee replacement, congestive heart failure and chronic obstructive pulmonary disease. The project's goal is to enable users to see how well their local hospitals care for patients who do not require the highest level of medical expertise and technology. The analysis, conducted in collaboration with Dr Foster, a London-based global health analytics firm, unearthed low volumes and troubling outcomes at hospitals many times larger than Sterling. The mortality rates published there, however, reflect overall mortality, not the relative risk of death from low-volume procedures. Joseph Scott, CEO of Jersey City Medical Center, acknowledged that the hospital may have had problems with its bypass surgery program during the years evaluated by U.S. News. "We have a different cardiac surgeon today than we did [then]," he says. "While [the findings] may be true between 2010 and 2012, we're always about continuous improvement and making things better." The first large study showing an indisputable link between low volumes and poorer outcomes appeared in 1979 as a special report in the New England Journal of Medicine. Regardless, large numbers of hospitals continue to do small numbers of procedures. Part of the U.S. News analysis identified every hospital across the nation that operated on or treated fewer than 25 traditional Medicare inpatients from 2010 through 2012 for nearly 20 frequent procedures and conditions. Among the findings for those ultra-low-volume hospitals: 1,071 performed 10,686 hip replacements, an average of 3.3 per year per hospital. 608 performed 6,707 knee replacements, an average of 3.7 per year. 124 performed basic heart bypass surgery on 1,538 patients, an average of 4.1 per year. 254 hospitals performed heart bypass surgery involving valve replacement or repair on 3,203 patients, an average of 4.2 per year. 396 hospitals treated 4,626 cases of heart failure, an average of 3.9 per year. 558 hospitals treated 7,174 cases of chronic obstructive pulmonary disease, an average of 4.3 per year. Because a single death more or less would make the calculated odds jump or plummet at these hospitals, U.S. News chose not to display their overall ratings in Best Hospitals for Common Care unless such a hospital had had five or more deaths in a procedure or condition. Nevertheless, taken together, the risk posed by ultra-low-volume hospitals is unmistakable. In the U.S. News analysis, knee-replacement patients at the hospitals had double the national average death risk, a 25 percent higher rate of readmission because of post-discharge complications. Hip-replacement patients faced a 77 percent higher risk of death and a 25 percent higher risk of readmission.
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