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Inside the U.S. News Best Children’s Hospitals Rankings
A v e r y C o m a r o w & c o l l e a g u e s
N O V E M B E R 3 , 2 0 1 6 W A S H I N G T O N , D . C .
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LEAD INVESTIGATORS
Avery Comarow Health Rankings Editor
Murrey Olmsted, Ph.D. Project Director, RTI
International
Ben Harder Chief of Health Analysis |
Managing Editor
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PERSPECTIVEONPUBLIC REPORTING
BestChildren’sHospitalsMission:Toprovidedecisionsupporttofamiliesandreferringphysiciansforchildrenwhosemedicalneedscallforthehighestqualityofcare.Qualityimprovementandpublicaccountabilityhaveimportantsocietalbenefitsbutaresecondarytothismission.
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D ISCLOSURES
OurGroup:• AveryComarowandBenHarderareemployedbyU.S.News&WorldReport.U.S.NewsissolesponsoroftheBestChildren’sHospitalsanalysisandreceivesrevenuesfrommulRpleadverRsersincludinghealthsystems.
• Dr.MurreyOlmstedisemployedbyRTIInternaRonal,U.S.NewscontractorforproducingtheBestChildren’sHospitalsrankings.
AveryComarow,MurreyOlmsted:Nodisclosures
BenHarder:• Part-RmeSeniorFellowatGuideStar• WifeisMedStarHealth-employedphysician• SisterisBrigham&Women’s-employedphysician
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TODAY’S DISCUSSIONAGENDA
Lookingaheadto2017Ø TimelyinclusionofallevaluatedhospitalsØ TransiRoningfromICD-9toICD-10Ø RethinkingdomainweightsinoneormorespecialResAddressingburdenofsurveyonhospitalsØ CompleRonRmeØ Enhancedhospitalve]ngØ SpecificsurveypainpointsDatachallengesØ PrelaunchdatareviewØ CatchingquesRonablevaluesØ LackofriskadjustmentØ PrevenRngerrorsUnderdiscussionØ IntroduceadvisertransparencyØ Splitmedical/surgicalspecialResØ Reworksurveyandinterface
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1.Timelyinclusionofallevaluatedhospitals
FollowingthemostrecentlaunchinJune,hospitalswereaddedthatwereevaluatedbutdidnotachieveatop-50ranking.Scoresaredisplayedinallvariablesotherthanoverallscoreorranking.In2017,suchhospitalswillbedisplayedatlaunchalongwithrankedhospitals.Resultsinindividualmetricsbutwithoutrankoroverallscorewillagainbeincluded.
LOOKINGAHEADTO2017
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2.TransiLoningfromICD-9toICD-10Weappreciatetheimpactonhospitals.WeareworkingtosmooththetransiRonandtominimizelargevolumeshiesbywordingquesRonsclearlyanddefiningcodesappropriately.IftransiRon-relatedcomplicaRonsthreatenRmelysurveycompleRon,we*may*beabletoallowextraRmecasebycase.AdvancenoRcewouldbehelpful.
LOOKINGAHEADTO2017
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3.RethinkingdomainweightsOutcomesmayreceiveaddiRonalweightincardiology&heartsurgery,forexample,becausemostoutcomesaretakenfromregistries. OnlyspecialReswithavarietyofrobustoutcomeswouldbeeligibleforsignificantweighRngchanges.Mosthaveafewgoodoutcomes,buttheyarerarelyrisk-adjusted.
LOOKINGAHEADTO2017
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SURVEYBURDEN: COMPLETIONTIME
1.AddingcompleLonLmeHospitalshaverequestedmorethanthecurrent4-6weekstheyhavehistoricallyreceivedaeerthesurveyisinthefieldinearlyJanuary.U.S.Newsresponse:TogivehospitalssixweekstopreparefortheJanuaryrelease,wewillpostaworkingdraeofthesurveyquesRonsonlinelaterthismonth.QuesRonsorconcernswithspecificmeasuresshouldberaisedduringthisperiod.
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SURVEYBURDEN: IN-HOUSEVETTING
2.EnhancinghospitalveSngSurveyresponsibilityatsomehospitalsisassignedtoindividualswhowouldbenefitfromassistanceprovidedbyclinicalleaders.U.S.Newsresponse:AhigherdegreeofclinicalengagementwouldspeedprocessingandimproveQCbothwithinhospitalsandbyRTIandU.S.News.
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SURVEYBURDEN: IN-HOUSEVETTING
2.EnhancinghospitalveSng(cont.)WerequireCMOsignoffonthecompletedsurveyandencourageservicechiefstobeinvolvedincollecRng,reviewingandsigningoffonresponsesfortheirspecialty.WealsocollecttheircontactinformaRonforpossiblefollow-up.Wemaymakeformalsignoffahardrequirementinthefuture.
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SURVEYBURDEN: PAINPOINTS
1.ImprecisequesLonsSomequesRonsmaybeopentomisinterpretaRon.U.S.Newsresponse:WeaskhospitalstoidenRfysuchquesRonsasapduringthesurveyperiodsowecanissueclarificaRons.Post-surveyfeedbackisalsohelpfulforworkinggroupstoconsiderrevisionsinfollowingyear.
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SURVEYBURDEN: PAINPOINTS
1.ImprecisequesLons(cont.)ExampleofclarificaRoninplacefor2017:IncancersecRon(Q.B27),idenRficaRonofbraintumorswillbeimprovedbyplacingtheminto5categories,withICD-10diagnosisandprocedurecodes.
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HOSPITAL SURVEYBURDEN: PAINPOINTS
2.ReporLngvolumedataHospitalssaygeneraRngvolumesisextremelyRme-consumingandindividualvolumemetricshavelowweight.OutpaRentsfrommulRpleclinicsoeenmustbecombinedandthenumbersmaynotbereadilyavailablefromtheEMRorthroughtheHITsystem.
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SURVEYBURDEN: PAINPOINTS
2.ReporLngvolumedata(cont.)U.S.Newsresponse:EffecRveoutpaRentcarelowersthenumberofsick,high-costinpaRents.Hospitalsagree.ThereforeoutpaRentcareshouldbeevaluated.OuradvisershavesuggestedthatforsomequesRonsahospitalcouldsimplyindicatewhetherornotitseesathresholdnumberofpaRents,suchas25ormore.ThepremiseisthathavingthefuncRonismoreimportantthanahighvolumeofpaRents.Weareconsideringthis.
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SURVEYBURDEN: PAINPOINTS
3.QuesLonsthatchangeyeartoyear.Somehospitalssetupsurvey-specificdataqueriestotheirEMRs.Changesmayrequirereprogramming.U.S.Newsresponse:WetrytomakechangesonlywhentheyleadtoimprovedmeasurementorreducethepotenRalformisinterpretaRon.
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SURVEYBURDEN: PAINPOINTS
4.InfecLonirrelevanceCLABSIandCAUTIareimmaterialinsomespecialRes.U.S.Newsresponse:Botharenowtrackedonlyincancer,gastroenterology&GIsurgery,cardiology&heartsurgery,nephrologyandpulmonology.InneonatologyonlyNICU-specificinfecRonsaretracked.UrologyonlytracksCAUTI.Neitheristrackedindiabetes&endocrinology,neurology&neurosurgery,ororthopedicsbecauseoffewerICUdays.
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SURVEYBURDEN: PAINPOINTS
5.QuesLonsrequiringchartreviewManyhospitalshavenotyetintegratedchartdataintotheirEMRs.RespondingtakesaninordinateRme.U.S.Newsresponse:WetrytominimizequesRonsrequiringchartreviewandreassessthevalueofeachsuchquesRoneveryyear.
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SURVEYBURDEN: PAINPOINTS
5.QuesLonsrequiringchartreview(cont.)Forexample,aquesRonthatwillbedeletedin2017askedforthe%ofvisitsinwhichcurrentcancerpaRentsseetheirprimaryoncologistformanagementandevaluaRon:
q ≥90% q 80-89% q 65-79% q 50-64% q Less than 50%
RespondingwasburdensomeandmayhaveledsomehospitalstosupplyesRmatesratherthanactualvalues.
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SURVEYBURDEN: PAINPOINTS
6.DifficultyprinLngoutcompletedsecLonsofonlinesurveyU.S.Newsresponse:ThesurveycanbedownloadedasaPDFandselectedpagescanthenbeprintedout.Tablesmaynotlookexactlythesameastheydoonscreen,buttheyarereadable.RTIwillconvertthecompletedonlinesurveytoaPDFforanyhospitalthatmakesarequest.Thisisregularlydoneforabout20hospitals.
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DATACHALLENGES
1.PrelaunchdatareviewHospitalswantaformalreviewprocesstovalidateourfindingsbeforetheyaremadepublic.U.S.Newsresponse:PosRngembargoedresultsforallmetricsonDashboardandproviding4weeksorsofordatareconciliaRonmightbepossible.ExtensivetechnicalinputandtesRngandsignificantcommitmentofaddiRonalU.S.Newsresourceswouldberequiredandthecurrentschedulewouldbedisrupted.
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DATACHALLENGES
2.CatchingquesLonablevaluesExampleswehavenotedincludeacross-the-board100%followuprates,highvolumeswithfewprovidersandsignificantyear-to-yearvolumechanges.U.S.Newsresponse:Wetargetimportantvaluesthatcanbequicklyaddressed.All100%responses,allvalues2-3SDfrommeanand“unlikely”valuesareflagged.Year-to-yearvariaRonisanoisytarget—mergers,newprogramsandotherfactorscreateunpredictablechange.
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DATACHALLENGES
2.CatchingquesLonablevalues(cont.)Flaggedexamplesfrom2016responses:• F33.1–Readmissionrate5Rmeshigherthanallother
hospitals.• H27–HospitalindicatedSSIratesaretrackedbut
providednorates.• G21d–NumberofkidneytransplantpaRentsexceeded
totalofallkidneypaRents.• J24e–Medianweight-for-lengthpercenRlewas3S.D.
belowthemean.
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DATACHALLENGES
3.LackofriskadjustmentRisk-adjustedoutcomeswouldbeserquanRfyhospitalperformancebyaccounRngforpaRentacuity.U.S.Newsresponse:ItwouldbetheoreRcallypossibleforhospitalstoprovideanonymizedpaRentrecordsdirectlytoU.S.News.Wewouldthenhavethedatanecessarytomeasurerisk-adjustedperformance.Thiswouldbeatarget,notanextstep.Planningwouldtakeseveralyearsormore.
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DATACHALLENGES
4.PrevenLngerrorsWeareintensifyingtheefforttominimizetheneedforpost-launchcorrecRons,whichcreatedifficulResforbothaffectedhospitalsandU.S.News.U.S.Newsresponse:AddiRonalchecksincludethefollowing—Ø Wehaveextendedthescopeofunlikelyvaluesby
buildingaddiRonal“if…then”logiccheckstoevaluatedataasitisenteredandalerRnghospitalstoimplausibleentries.
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DATACHALLENGES
4.PrevenLngerrors(cont.)
Ø WeanRcipateincreasingthenumberofspecifichospitalswewillflagtorequestthattheyvalidateorcorroboratetheirsubmiseddata.
Ø WewillstepupscruRnyoflargeyear-to-yeardatachanges.Asnoted,suchshiesdonotalwaysrepresentareporRngproblem,buttheyinviteacloserlook.
Ø Wewillconsidershowingeachhospital’senRrescorecardintheDashboard—notjustitsrank—duringtheembargoperiod.
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UNDERDISCUSSION
1.Introduceadvisertransparency
HospitalsandvariousorganizaRonsandindividualshaveaskedustoidenRfyworkinggroupmembersandtheirhospitals.U.S.Newsresponse:WeendorsetransparencybutdonotwanttosubjectadviserstopressureordistracRons(e.g.unsolicitedcallsandemails),especiallydecisionsonmethodologyarenottheirsbutrestwithU.S.News.
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UNDERDISCUSSION
2.Splitmedical/surgicalspecialLesSeparatelyevaluaRngspecialResincombinaRonssuchascardiology&heartsurgerywouldprovidefamilieswithinformaRonthatisbeserfocused.U.S.Newsresponse:ConcernsincluderelaRvelylowvolumesinthedividedspecialRes,lackofnon-surgicaloutcomesinsomemedicalspecialRes,andinterlockingclinicalrelaRonshipsthatcannotbereadilyseparated.
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UNDERDISCUSSION
3.Beyondclarifyingandpruning,canthesurveyanditsinterfacebesignificantlyimprovedtoexpeditecompleLon?U.S.Newsresponse:BothU.S.NewsandRTIwelcomesuggesRonsonhowtoaccomplishthisworthwhilegoal.
