Methodology

• Performance Data:
  • Process-of-Care, HCAHPS, Mortality Rates, Readmission Rates, and Average Reimbursement Rates (CMS Hospital Compare)
  • Bloodstream Infections (Consumers Union and Leapfrog Group)
  • Inpatient Quality Indicators, Patient Safety Indicators, and Prevention Quality Indicators (Agency for Healthcare Research and Quality/states)
  • Health Information Technology Adoption (American Hospital Association survey)
  • Population Health, and Utilization and Costs (Institute of Medicine)
• Data Not Available
  • N/A
• Composite Quality Measures--Recommended Care for Heart Attack, Heart Failure, Pneumonia, and Surgical Care
• Composite Quality Measure--Overall Recommended Care (Across the Four Conditions)
• Top Performers
• Benchmarks
• Map

Performance Data

Process-of-Care, HCAHPS, Mortality Rates, Readmission Rates, and Average Reimbursement Rates (CMS Hospital Compare)

WhyNotTheBest.org includes performance data reported publicly on the Centers for Medicare and Medicaid Services (CMS) Web site, Hospital Compare.  Specifically, it includes:

• 29 Hospital Quality Alliance (HQA) measures that report how often hospitals delivered recommended care processes in the following four areas: heart attack, heart failure, pneumonia, and surgical care improvement. The site currently includes data from over 5,200 institutions.  These process-of-care, or "core," measures are reported for all patients (i.e., not just Medicare patients). Only measures for which there are four quarters' worth of data are reported on the site. This includes three "legacy" measures, which CMS has retired and for which hospitals are no longer required to report data.
• 10 measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). This survey asks a random sample of recently discharged patients about important aspects of their hospital experience. These measures are reported for all patients. This site includes HCAHPS data from over 4,700 hospitals.  HCAHPS is a relatively new survey, and hospitals across the U.S. are not yet achieving very high scores across all of the questions. Nevertheless, some hospitals are scoring significantly better than others. HCAHPS measures are reported for all patients. Patients rate certain questions on a scale of 0 to 10, where 0 is the worst and 10 is the best. Responses to other questions consist of the following possible answers: Always, Usually, Sometimes, or Never.  For example, one survey question asks how often their nurses communicated well, and respondents reported their nurses ("Always," "Usually," "Sometimes," or "Never") communicated well. For more information on HCAHPS, visit the HCAHPS Web site: www.hcahpsonline.org.
• Readmission rates. This includes patients readmitted to a hospital within 30 days of discharge from a previous hospital stay for heart attack, heart failure, or pneumonia. Readmission rates are reported for Medicare patients only.  Readmissions rates displayed on this site reflect three years' worth of data from over 4,750 hospitals. The site also includes a composite measure as calculated by CMS: average Medicare hospital 30-day readmission rates for heart failure, heart attack, and pneumonia.  For more information, visit the CMS Hospital Compare Web site.
• Mortality rates. The rates take into account deaths within 30 days from all causes after an initial hospitalization with a principal diagnosis of heart attack, heart failure, or pneumonia. Mortality rates are reported for Medicare patients only.  Mortality rates displayed on this site reflect three years'  worth of data from over 4,750 hospitals. The site also includes a composite measure as calculated by CMS: average Medicare hospital 30-day mortality rates for heart failure, heart attack, and pneumonia.  For more information, visit the CMS Hospital Compare Web site.
• Medicare reimbursement rates for patients whose primary diagnosis was: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, or diabetes. Rates are also reported for patients undergoing: cardiac pacemaker implants, hernia procedures, laparoscopic cholecystectomy, or major joint replacement. The rates are reported at the hospital level and for Medicare patients only.  Medicare payments for the same diagnosis-related group may vary. According to CMS, a hospital may get a higher payment for any or all of the following reasons:
  • It is classified as a teaching hospital
  • It treats a high percentage of low-income patients (disproportionate share)
  • It may treat unusually expensive cases (outlier payments)
  • It pays its employees more compared to the national average because the hospital is in a high-cost area (wage index). Note: The hospital's wage index is calculated using the hospital's payroll records, contracts and other wage related documentation.

Bloodstream Infections (Consumers Union and Leapfrog Group)

WhyNotTheBest.org includes data on the incidence of central line-associated bloodstream infections (CLABSIs) , a type of infection introduced when a central-line catheter or tube is placed in a large vein in the neck, chest, or arm to enable the rapid administration of fluids, blood, or medications to critically ill patients.   CLABSIs can be prevented through proper insertion and care of the central line. 

The data come from 16 states - California, Colorado, Delaware, Illinois, Maine, Massachussets, Missouri, New Hampshire, New Jersey, New York, Oregon, Rhode Island, South Carolina, Tennessee, Vermont, and Virginia - in which hospitals report data as a result of state laws as well as from 43 states in which some hospitals have voluntarily reported infection data to The Leapfrog Group (these states are AK, AL, AZ, CA, CO, CT, DC, DE, FL, GA, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MN, MI, MO, MS, NC, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI, WY). In all, the site includes data from 1,571 hospitals. The data were made available by special arrangement with Consumer Reports Health, which integrated data from each of the states and from the Leapfrog Group to produce the results displayed here.  In some states, data come from both The Leapfrog Group and the state, in which case, the most recent hospital data is reported.  To locate hospitals reporting CLABSI data, search via hospitals' Location/Characteristics using the "Hospitals Reporting…" filter, choosing the "Health Care-Associated Infections" option.  Or, follow the shortcuts to view performance data for hospitals in a particular state listed above. 

The risk of infection varies across different types of intensive care units (ICUs).  Therefore, the CLABSI data are reported as standardized infection ratios (SIRs), a measure developed by the Centers for Disease Control and Prevention to summarize comparisons of data from an individual ICU to national infection rates for that particular type of ICU.

This analysis adjusts for the fact that Leapfrog and the states have data from varying  ICU mixes, requiring comparisons to different average infection rates.  For instance, the average infection rate for cardiac ICUs nationwide is two per 1,000 central line days, so a particular cardiac ICU with a rate of three infections per 1,000 days has 50 percent more infections than average. For surgical ICUs, the national average rate is 2.3 infections per 1,000 central line days, so a surgical ICU reporting a rate of 4.6 infections per 1,000 central line days has 100 percent more infections than average.  The SIR pools these comparisons across all ICUs for which a hospital reports CLABSI data.

Thus a SIR = 1 means that the hospital's ICUs produced CLABSIs at the same rate overall as would be predicted from national rates for the particular mix of ICUs for which that hospital reported data.  A SIR > 1 indicates the hospital had more infections than predicted from national rates, and a SIR < 1 implies it had fewer infections than predicted. So, for example, a hospital with a SIR of 1.50 reported 50 percent more infections than would be predicted from national rates, and one with a SIR of 0.70 reported 30 percent fewer infections than national rates for its mix of ICUs.

We publish reported infections for all hospitals that meet either of the following sample size requirements:

• At least 1,000 central line days (CLDs) OR
• At least three infections, regardless of the number of central line days.  A hospital that reports three or more infections, even in fewer than 1,000 CLDs, could not achieve better than a rate of three infections/1,000 CLDs; this is 50 percent higher than the national infection rate for medical ICUs.

In summary, the Standardized Infection Ratio is calculated as follows:

1. For each reporting ICU, multiply the number of central line days by the published national infection rate for the ICU type, divided by 1,000, to estimate the number of infections predicted for that ICU if it were to report CLABSIs at the same frequency as the national rate (CLD x national rate / 1,000). 
2. Within each hospital, calculate the sum of predicted infections and the sum of reported infections across all reporting ICUs.
3. Calculate SIR = (total reported infections/total predicted infections).   For CLABSI data, a SIR of 1.0 indicates that a hospital is performing just as would be predicted from national rates.

Data Limitations: Most hospitals that track the incidence of central line-associated bloodstream infections in their intensive care units (ICUs) rely on infection preventionists to manually identify such infections. Based on definitions from the Centers for Disease Control and Prevention, these individuals use objective criteria, such as positive blood culture, as well as subjective criteria, such as determining whether recovery of a common skin commensal in the blood represents a true infection vs. a contamination, to identify bloodstream infections. Recently, a computer algorithm has been developed for identifying bloodstream infections through objective criteria only; the algorithm thus provides an objective standard against which to benchmark infection preventionists' determination of infection rates.

A recent study published in the Journal of the American Medical Association compared rates of infections identified by infection preventionists at 20 ICUs in four medical centers with those found at the same ICUs through the computer algorithm. The researchers found significant differences between infection rates identified by the two different methods—suggesting that surveillance methods may vary across hospitals due to varying application of standard definitions of bloodstream infections. The researchers say their findings raise concerns about the validity of comparisons across medical institutions and call for surveillance measures that are as reliable and objective as possible.   
 

For more information on the methodology and data limitations, please see the Consumer Reports Health Web Site. 

Inpatient Quality Indicators, Patient Safety Indicators, and Prevention Quality Indicators (Agency for Healthcare Research and Quality/states)

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) are measures of health care quality that make use of readily available hospital inpatient administrative data. These measures are reported for all patients (i.e., not just Medicare patients).

On WhyNotTheBest.org, we report on a subset of the Inpatient Quality Indicators (IQIs), Patient Safety Indicators (PSIs), and Prevention Quality Indicators (PQIs), the latter of which are available on the map only.

Currently, we have data on this site for the IQIs in over 1,700 hospitals and for the PSIs in over 1,920 hospitals in 12 states:  Arizona, California, Florida, Illinois, Maryland, New Hampshire, New Jersey, New York, Rhode Island, Texas, Vermont, and Washington.   Additionally, we have data for PQIs in 655 counties within the 12 states listed above.  The Commonwealth Fund's publication of the AHRQ Quality Indicators means that--for the first time--performance data from multiple states can be compared side by side.

While most data on the Web site are collected nationally under strict standards, data for the AHRQ measures are collected by the states and are therefore subject to minor variations in the method and manner of collection, validation, and reporting. Users are cautioned that comparing facilities across state lines may be less accurate than similar comparisons using federal data. All quality measures go through periods of development, refinement, and standardization, and we expect the consistency of these measures to improve over time.

The Inpatient Quality Indicators (IQIs) are a set of measures that reflect quality of care inside hospitals; they include mortality rates, utilization rates, and volume.  We report eight IQIs on WhyNotTheBest.org because they are either endorsed by the National Quality Forum or related to conditions reported in other data sets included here (i.e., acute myocardial infarction, heart failure, and pneumonia). 

• Risk-adjusted Mortality Rates for Medical Conditions -Congestive heart failure IQI 16 - This measure is used to assess the number of deaths per 100 discharges with principal diagnosis code of congestive heart failure (CHF).
• Risk-adjusted Mortality Rates for Medical Conditions -- Stroke IQI 17 - This measure is used to assess the number of deaths per 100 discharges with principal diagnosis code of stroke.
• Risk-adjusted Mortality Rates for Medical Conditions -- Hip fracture IQI 19 - This measure is used to assess the number of deaths per 100 discharges with principal diagnosis code of hip fracture.
• Risk-adjusted Mortality Rates for Medical Conditions,--Pneumonia IQI 20 - This measure is used to assess mortality per 100 discharges with principal diagnosis code of pneumonia.
• Risk-adjusted  Mortality Rates for Medical Conditions -- Acute myocardial infarction (AMI) IQI 15 --  This measure is used to assess the number of deaths per 100 discharges with the principle diagnosis of heart attack (acute myocardial infarction).
• Coronary artery bypass graft (CABG) - area rate IQI 26 (MAP ONLY) - This measure is used to assess the number of coronary artery bypass grafts (CABGs) per 100,000 population.
• Percutaneous transluminal coronary angioplasty  -(PTCA) - area rate IQI 27 (MAP ONLY) - This measure is used to assess the number of percutaneous transluminal coronary angioplasty (PTCA) procedures per 100,000 population.
• Hysterectomy - area rate IQI 28 (MAP ONLY) -- This measure is used to assess the number of hysterectomies per 100,000 female population.

The IQIs include five measures of mortality rates, which have been shown to vary across institutions and there is evidence that high mortality may be associated with worse quality of care.  WhyNotTheBest.org thus includes two different types of mortality data from two different sources.

• CMS Hospital Compare -- CMS mortality rates are 30-day, all-cause mortalities among patients hospitalized with a principal diagnosis of heart attack, heart failure, and pneumonia. All-cause mortality is defined as death from any cause within 30 days after the admission date, regardless of whether the patient dies while still in the hospital or after discharge. It measures deaths that occur within 30 days of a hospital admission, rather than inpatient mortality only, or mortality over some other post-discharge period. The CMS mortality rates measure deaths among Medicare patients only.
• AHRQ Inpatient Quality Indicators -- AHRQ defines mortality as in-hospital mortality following procedures  for common medical conditions. It measures mortality among all patients -- not just those in Medicare.

The Patient Safety Indicators reflect quality of care inside hospitals, but focus on potentially avoidable complications and adverse events following surgeries, procedures, and childbirth. The PSIs were developed after a comprehensive literature review, analysis of ICD-9-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses. On this site we report the following PSIs:

For some states there is no data available for certain PSIs. For these indicators, an N/A  will be displayed.

• Risk-adjusted Failure to Rescue PSI 4 -- This measure is used to assess the number of deaths per 100 patients having developed specified complications of care during hospitalization.
• Risk-adjusted Postoperative pulmonary embolism or deep vein thrombosis PSI 12 -- This measure is used to assess the number of cases of deep vein thrombosis (DVT) or pulmonary embolism (PE) per 100 surgical discharges with an operating room procedure.
• Risk-adjusted Decubitus ulcer PSI 3 -- This measure is used to assess the number of cases of decubitus ulcer per 1,000 discharges with a length of stay greater than 4 days.
• Risk-adjusted Selected Infections Due to Medical Care PSI 7 -- This measure is used to assess the number of cases of infections per 1,000 discharges. The Central Venous Catheter-related Blood Stream Infections indicator is intended to flag cases of infection due to medical care, primarily those related to intravenous (IV) lines and catheters.
• Risk-adjusted Postoperative hip fracture PSI 8 -- This measure is used to assess the number of cases of in-hospital hip fracture surgical discharges with an operating room procedure.
• Risk-adjusted Postoperative Sepsis PSI 13 -- This measure is used to assess the number of cases of sepsis per 1,000 elective surgery patients with an operating room procedure and a length of stay of 4 days or more.
• Transfusion reaction PSI 16 -- This measure is used to assess the number of cases of transfusion reaction either from incompatible or mismatched blood.
• Foreign body left during procedure - area rate PSI 21 (MAP ONLY) -- This measure is used to assess the number of discharges with foreign body accidentally left in during procedure per 100,000 population.
• Iatrogenic pneumothorax - area rate PSI 22 (MAP ONLY) -- This measure is used to assess the number of cases of iatrogenic pneumothorax per 100,000 population.
• Selected infections due to medical care - area rate PSI 23 (MAP ONLY) -- This measure is used to assess the number of cases of infections per 100,000 population. The Central Venous Catheter-related Blood Stream Infections indicator is intended to flag cases of infection due to medical care, primarily those related to intravenous (IV) lines and catheters.
• Accidental puncture or laceration - area rate PSI 25 (MAP ONLY) -- This measure is used to assess the number of cases of technical difficulty (e.g., accidental cut or laceration during procedure) per 100,000 population.
• Transfusion reaction - area rate PSI 26 (MAP ONLY) -- The Transfusion Reaction indicator is intended to flag cases of major reactions due to transfusions (ABO and Rh). This indicator is defined both on a provider level (by including cases based on secondary diagnosis associated with the same hospitalization) and on an area level (by including all cases of transfusion reactions).
• Postoperative hemorrhage or hematoma requiring a procedure - area rate PSI 27 (MAP ONLY) -- This measure is used to assess the number of cases of hematoma or hemorrhage requiring a procedure per 100,000 population.

We report the following county-level PQIs (MAP ONLY):

• Overall Preventive Care (PQI 90) -- AHRQ collects various measures related to preventive quality improvement. This measure is a weighted average of those measures collected by AHRQ. Only hospitals that saw 30 or more patients are included. The composite measure takes into account nearly all PQIs, including: PQI 1 - Diabetes Short-Term Complications Admission Rate; PQI 3 - Diabetes Long-Term Complications Admission Rate; PQI 5 - Chronic Obstructive Pulmonary Disease or Asthma in Older Adults Admission Rate; PQI 7 - Hypertension Admission Rate; PQI 8 - Congestive Heart Failure Admission Rate;  PQI 10 - Dehydration Admission Rate; PQI 11  - Bacterial Pneumonia Admission Rate; PQI 12 - Urinary Tract Infection Admission Rate; PQI 13 - Angina  Without Procedure Admission Rate; PQI 14 - Uncontrolled Diabetes Admission Rate; PQI 15 - Asthma in Younger Adults Admission Rate; and PQI 16 - Rate of Lower-Extremity Amputation Among Patients with Diabetes.
• Overall Acute Preventive Care (PQI 91) -- AHRQ collects various measures related to preventive quality improvement of acute conditions. This measure is a weighted average of those measures collected by AHRQ. Only hospitals that saw 30 or more patients are included. The composite measure takes into account: PQI 10 - Dehydration Admission Rate; PQI 11 - Bacterial Pneumonia Admission Rate; and PQI 12 - Urinary Tract Infection Admission Rate.
• Overall Chronic Preventive Care (PQI 92) -- AHRQ collects various measures related to preventive quality improvement of chronic conditions. This measure is a weighted average of those measures collected by AHRQ. Only hospitals that saw 30 or more patients are included. The composite measure takes into account: PQI 1 - Diabetes Short-Term Complications Admission Rate; PQI 3 - Diabetes Long-Term Complications Admission Rate; PQI 5 - Chronic Obstructive Pulmonary Disease or Asthma in Older Adults Admission Rate; PQI 7 - Hypertension Admission Rate; PQI 8 - Congestive Heart Failure Admission Rate;  PQI 13 - Angina Without Procedure Admission Rate; PQI 14 - Uncontrolled Diabetes Admission Rate; PQI 15 - Asthma in Younger Adults Admission Rate; and PQI 16 - Rate of Lower-Extremity Amputation Among Patients with Diabetes.
• Perforated Appendix (PQI 2) -- This measure is used to assess the number of admissions for perforated appendix per 100 admissions for appendicitis within a county. As a Prevention Quality Indicator (PQI), admission for perforated appendix is not a measure of hospital quality, but rather one measure of outpatient and other health care.
• Hypertension Admissions (PQI 7)  -- This measure is used to assess the number of admissions for hypertension per 100,000 population. As a Prevention Quality Indicator (PQI), hypertension is not a measure of hospital quality, but rather one measure of outpatient and other health care. Providers may reduce admission rates without actually improving quality by shifting care to an outpatient setting.
• Uncontrolled Diabetes Admissions (PQI 14)  -- This measure is used to assess the number of admissions for uncontrolled diabetes per 100,000 population.As a Prevention Quality Indicator (PQI), uncontrolled diabetes is not a measure of hospital quality, but rather one measure of outpatient and other health care. Rates of diabetes may vary systematically by area, creating bias for this indicator.
• Adult Asthma Admissions (PQI 15)  This measure is used to assess the number of admissions for asthma in adults per 100,000 population. As a Prevention Quality Indicator (PQI), adult asthma is not a measure of hospital quality, but rather one measure of outpatient and other health care. Providers may reduce admission rates without actually improving quality by shifting care to an outpatient setting. Admission rates that are drastically below or above the average or recommended rates should be further examined.
• Dehydration Admissions (PQI 10)  --This measure is used to assess the number of admissions for dehydration per 100,000 population. As a Prevention Quality Indicator (PQI), dehydration is not a measure of hospital quality, but rather one of the measures of outpatient and other health care.
  This indicator has unclear construct validity, because it has not been validated except as part of a set of indicators. Providers may reduce admission rates without actually improving quality by shifting care to an outpatient setting. Some dehydration care takes place in emergency rooms. As such, combining inpatient and emergency room data may give a more accurate picture of this indicator.
• Bacterial Pneumonia Admissions (PQI 11)  --This measure is used to assess the number of admissions for bacterial pneumonia per 100,000 population. As a Prevention Quality Indicator (PQI), admission for bacterial pneumonia is not a measure of hospital quality, but rather one measure of outpatient and other health care.This indicator has unclear construct validity, because it has not been validated except as part of a set of indicators. Providers may reduce admission rates without actually improving quality by shifting care to an outpatient setting. Because some pneumonia care takes place in an emergency room setting, combining inpatient and emergency room data may give a more accurate picture of this indicator.
• Urinary Tract Infection Admissions (PQI 12) --This measure is used to assess the number of admissions for urinary tract infection per 100,000 population. As a Prevention Quality Indicator (PQI), admission for urinary tract infection is not a measure of hospital quality, but rather one measure of outpatient and other health care. This indicator has unclear construct validity, because it has not been validated except as part of a set of indicators. Providers may reduce admission rates without actually improving quality by shifting care to an outpatient setting. Some urinary tract infection care takes place in emergency rooms. As such, combining inpatient and emergency room data may give a more accurate picture of this indicator.
• Angina Admissions (PQI 13)  --This measure is used to assess the number of admissions for angina (without procedures) per 100,000 population.
  As a Prevention Quality Indicator (PQI), angina without procedure is not a measure of hospital quality, but rather one measure of outpatient and other health care. This indicator has unclear construct validity, because it has not been validated except as part of a set of indicators. Providers may reduce admission rates without actually improving quality of care by shifting care to an outpatient setting. Some angina care takes place in emergency rooms. Combining inpatient and emergency room data may give a more accurate picture.
• Lower Extremity Amputations (PQI 16)  --This measure is used to assess the number of admissions for lower-extremity amputation among patients with diabetes per 100,000 population. As a Prevention Quality Indicator (PQI), lower-extremity amputations among patients with diabetes is not a measure of hospital quality, but rather one measure of outpatient and other health care. PQIs are correlated with each other and may be used in conjunction as an overall examination of outpatient care.
• Diabetes Short-term Complications Admissions (PQI 1)  --This measure is used to assess the number of admissions for diabetes short-term complications per 100,000 population.As a Prevention Quality Indicator (PQI), short-term diabetes complication rate is not a measure of hospital quality, but rather one measure of outpatient and other health care. Rates of diabetes may vary systematically by area, creating bias for this indicator. Examination of both inpatient and outpatient data may provide a more complete picture of diabetes care.
• Congestive Heart Failure Admissions (PQI 8)  --This measure is used to assess the number of admissions for congestive heart failure (CHF) per 100,000 population.As a Prevention Quality Indicator (PQI), CHF is not a measure of hospital quality, but rather one measure of outpatient and other health care. Providers may reduce admission rates without actually improving quality by shifting care to an outpatient setting.Some CHF care takes place in emergency rooms. As such, combining inpatient and emergency room data may give a more accurate picture of this indicator.
• Diabetes Long-term Complications Admissions (PQI 3)  --This measure is used to assess the number of admissions for diabetic long-term complications per 100,000 population. As a Prevention Quality Indicator (PQI), diabetes long-term complication rate is not a measure of hospital quality, but rather one measure of outpatient and other health care. Rates of diabetes may vary systematically by area, creating bias for this indicator. Examination of both inpatient and outpatient data may provide a more complete picture of diabetes care.
• Chronic Obstructive Pulmonary Disease Admissions (PQI 5)--This measure is used to assess the number of admissions for chronic obstructive pulmonary disease (COPD) per 100,000 population. As a Prevention Quality Indicator (PQI), COPD is not a measure of hospital quality, but rather one measure of outpatient and other health care. This indicator has unclear construct validity, because it has not been validated except as part of a set of indicators. Providers may reduce admission rates without actually improving quality by shifting care to an outpatient setting. Some COPD care takes place in emergency rooms, so combining inpatient and emergency room data may give a more accurate picture.

For additional information about AHRQ measures and risk adjustment, refer to http://www.qualityindicators.ahrq.gov/.

Interpretation:

Around each measure’s rate we calculate the 95 percent confidence interval, which takes the denominator into account.  A rate with a small denominator would yield a very wide confidence interval, and a large denominator would yield a smaller confidence interval.  If the statewide rate falls within the hospital’s confidence interval then there is no statistically significant difference between the hospital and the statewide rate.  If the statewide rate falls outside of the hospital’s confidence interval then there is a statistically significant difference.  For measures where a higher rate is desirable and the hospital's confidence intervals are above the statewide rate, then the hospital is reported as performing better than the state. Conversely, for measures where a lower rate is desirable and the hospital's confidence intervals falls below the statewide rate, then the hospital is reported as performing better than the state.

Health Information Technology Adoption (American Hospital Association survey)

The site includes three measures assessing the use of health information technology (HIT): 1) Hospital electronic medical record (EMR) adoption indicates whether a hospital has adopted a basic or comprehensive EMR; 2) Percent of admissions within the region taking place at hospitals with at least a Basic EMR -- shown on the map only; and 3) Percent of admissions within the region taking place at hospitals with a Comprehensive EMR-- shown on the map only. The data come from the American Hospital Association's electronic health record adoption database, which provides information on indicators that illustrate the depth and level of technology integration within hospitals.

To be qualified as a comprehensive electronic medical record system, the system must: 1) record patients' clinical and demographic data, 2) enable users to view and manage results of laboratory tests and imaging, 3) enable users to manage order entry (including electronic prescriptions), and 4) support clinical decision-making (including warning about drug interactions or contraindications). The principal differences between a comprehensive EMR system and a basic EMR system are the absence of certain order-entry capabilities and clinical decision support in a basic system. 

Population Health, and Utilization and Costs (Institute of Medicine)

The site includes the following measures of population health:

• Average Hierarchical Condition Category (HCC) risk score expressed as a Ratio to the National Average (see definition below);
• Percent of Medicare beneficiaries with Diabetes; and
• Percent of Medicare beneficiaries with Heart Failure.  

It also includes the following measures of utilization and costs:

• Standardized Risk-Adjusted Per Capita Costs -- total annual Medicare payments per beneficiary standardized to remove geographic differences in payment rates for individual services and adjusted for differences in beneficiaries’ health using the risk-adjusted model that CMS uses to pay Medicare Advantage plans;
• Inpatient Days Per 1000 Beneficiaries -- annual number of hospital inpatient days covered by Medicare per 1,000 Medicare beneficiaries in the geographic area, including inpatient acute care hospitals paid under the Prospective Payment System (PPS), critical access hospitals, and other inpatient hospitals as inpatient psychiatric facilities and cancer hospitals;
• Imaging (IMG) standardized per user Medicare costs -- total annual Medicare payments for imaging services per Medicare beneficiary in the geographic area who used imaging services during the year, standardized to remove geographic differences in payment rates for imaging services;
• Lab Tests service events per 1000 Medicare beneficiaries -- annual number of lab tests per 1,000 Medicare beneficiaries in the geographic area; and
• Emergency Department Visits per 1000 Beneficiaries -- annual number of hospital emergency department visits (including both visits that result in an admission and visits that do not result in an admission) per 1,000 Medicare beneficiaries in the geographic area.

These measures are reported at the HRR level, and for Medicare patients only. They are drawn from the Institue of Medicine's datasets on geographic variation.

The Hierarchical Condition Category (HCC) risk score model is used by CMS to adjust capitation payments to private health care plans for the health expenditure risk of their enrollees. The model measures disease burden, taking into account HCC categories, which are correlated to diagnosis codes. The following explanation comes from the Institute of Medicine (IoM) site: 

Data Not Available

Note that not all hospitals report data for all measures; the site only publishes data when there are at least four quarters' worth of data available for a particular measure.  Not all hospitals report all data for all measures.

There is never data available in certain cases:

• There are no state averages for readmissions and CMS mortality measures.
• There are no top 1 percent, top 10 percent or top 25 percent benchmark data for reimbursement rates.
• There are no top 25 percent benchmark data for mortality rates and readmission rates
• There are no benchmark data for HCAHPS ratings of 7 or 8.  There are also no benchmark data for HCAHPS rating 6 or lower (except for state and national averages).
• There are no state or national averages for CLABSIs.
• There are no national benchmark data for the AHRQ Inpatient Quality Indicators and Patient Safety Indicators.

N/A

In some cases, data is not reported by a facility or is not calculated for a benchmark.  In other cases, data is reported but does not meet the minimum criteria for inclusion.  In the latter case, N/A will be accompanied by a footnote.

Composite Quality Measures -- Recommended Care for Heart Attack, Heart Failure, Pneumonia, and Surgical Care

In addition to reporting performance for each process-of-care measure, WhyNotTheBest.org presents summary performance scores for each hospital for each of the following four conditions:

• Overall Heart Attack Summary Rate (composite of seven process-of-care measures for this condition)
• Overall Heart Failure Summary Rate (composite of four process-of-care measures for this condition)
• Overall Pneumonia Summary Rate (composite of six process-of-care measures for this condition)
• Overall Surgical Care Improvement Summary Rate (composite of nine care processes used to improve surgical care/prevent surgical infections)

To create composite scores for each condition, the site uses a methodology prescribed by the Joint Commission. This approach suggests that the composite score be the number of times a hospital performed the appropriate action across all measures for that condition, divided by the number of opportunities the hospital had to provide appropriate care for that condition. Composite scores will not be displayed if all measures in that condition were less than 30 cases.

Scores are not weighted, except that measures with larger denominators do contribute more weight to the calculation of the mean for that measure. None of the measures is risk adjusted.

Composite Quality Measure -- Overall Recommended Care (Across the Four Conditions)

In addition to creating composite quality scores for each of the four CMS clinical conditions, we create an overall quality composite (Overall Recommended Care) that takes into account 26 Hospital Quality Alliance process-of-care measures (excluding the three legacy measures that are no longer being collected).

It is possible for a hospital to submit “0” on a particular measure, indicating that it had no patients whose treatment was relevant to that measure. For example, a hospital reporting seven measures of heart attack care could submit denominators of 0, 6, 2, 12, 30, 29, and 14 and still have a composite score calculated.

In all instances we calculate a weighted average, wherein we add all the numerators and divide by the total of the denominators.

We also rank hospitals on these composite measures, but to be ranked hospitals must satisfy the following additional criteria:

• Measures must contain all available quarters worth of data.
• Must report all indicators within the topics (i.e. be fully reported). For example, HF composite score will be ranked only if all 4 HF indicators were reported.
• At least one indicator in the topic had denominator >= 30.

Some hospitals report enough data to be considered eligible for inclusion in the WhyNotTheBest.org top performers listing. These criteria are detailed below.

Top Performers

For each measure included on the site (excluding reimbursement rates, CLABSI data, and AHRQ IQIS and PSIs), the site identifies the top 1 percent of performers—the “top performers.” It also includes other benchmarks: the top 10 percent and the top 25 percent, as well as top performers by hospital type (e.g., safety net, teaching, etc.).

Top Performers on Process-of-Care Measures
To appear among the top performers on the CMS process-of-care measures, a hospital must have reported data for every available measure and recorded data on 30 or more patients for each of the four conditions (heart failure, heart attack, pneumonia, and surgical care improvement).

No explicit weighting was incorporated, but higher-occurring cases give weight to that measure in the average. Since these are process measures (versus outcome measures), no risk adjustment was applied. 

Top Performers on HCAHPS
To appear among the top performers on the HCAHPS data, hospitals are ranked according to the percentage of survey respondents giving a 9 or 10 rating of overall hospital care. The site uses the results of the following question as a measure of patients' overall experiences:

"Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?"

Note that the site does not apply exclusion criteria to create these performance rankings. All hospitals are included in the calculation of the percentile scores.

Top Performers on Readmission and Mortality Rates
The site identifies hospitals whose performance is statistically better than the national rate, as reported on Hospital Compare.

Benchmarks

For the purposes of calculating benchmarks, we identified hospitals in the following way:

• Safety Net Hospitals: membership in the National Association of Public Hospitals and Health Systems and/or serving 30 percent or more Medicaid patients
• Rural Hospitals: Hospitals designated by CMS as Critical Access Hospitals
• Teaching Hospitals: membership in the Council of Teaching Hospitals and Health Systems
• Academic Health Centers: membership in the American Academy of Medical Colleges
• For-Profit: based on ownership, from the American Hospital Association database
• Not-for-Profit/Private: based on ownership, from the American Hospital Association database
• Government – Non-Federal: based on ownership, from the American Hospital Association database
• Government – Federal: based on ownership, from the American Hospital Association database
• Health Systems: based on system classification from the American Hospital Association database
  A system is defined by AHA as either a multihospital or a diversified single hospital system. A multihospital system is two or more hospitals owned, leased, sponsored, or contract managed by a central organization. Single, freestanding hospitals may be categorized as a system by bringing into membership three or more, and at least 25 percent, of their owned or leased non-hospital preacute or postacute health care organizations. System affiliation does not preclude network participation. Read more about health systems.
  Note that these multi-hospital systems are often horizontally integrated collections of hospitals—as opposed to integrated delivery systems, which WhyNotTheBest.org defines as a system with two or more facilities, including one non-hospital (e.g., a nursing home). The integrated delivery systems identified on the WhyNotTheBest.org map are drawn from an SDI list of high-performing systems; for more information please see the SDI Web site.

Top 1 percent, Top 10 percent, Top 25 percent: Top n percent  is the lowest score achieved by a hospital in the top n percent (i.e. the minimum threshold to be in the top n percent).

Map

The WhyNotTheBest.org interactive map shows performance variation on the national, state, county and hospital referral region (HRR) levels. It also includes overlays showing quality improvement activity and performance recognition in various ways, as described below.

Performance Measures

The map includes the following performance measures: 

• Process-of-care "core" measures; 
• HCAHPS patient experience measures;
• CMS Mortality rates;
• CMS Readmission rates;
• Health Information Technology Adoption;
• Population Health, and Utilization and Costs;
• Select Inpatient Quality Indicators (area rates -- see above);
• Select Patient Safety Indicators (rates per 100,000 population - see above); and
• Select Prevention Quality Indicators (see above).

For the CMS measures, the hospital performance values were adjusted by the denominator so that hospitals with higher reported numbers of observations carried a greater weight toward the county rate.  Weighting was also used to address hospitals that share identifiers.  CMS Hospital Compare provides data at the level of Medicare Provider Numbers (MPNs).  For the map, hospitals sharing MPNs were weighted so as to not overcount their data.  This also allowed hospitals to contribute to the county rate, regardless of whether their shared MPNs crossed counties.  The HCAHPS measures are an exception.  As denominators are not provided for these data, we instead calculate an unweighted average.  Note: for some counties there are no data displayed, since there are no hospitals located in that county.

Overlays