Treat the entire patient, says Healthgrades, which emphasizes that knee surgery needs to focus on more than the knee.


Oct. 21—If all hospitals performed as well as the top-rated facilities, then potentially 223,412 lives could have been saved and 162,215 complications could have potentially been avoided, according to Healthgrades analysis of data from 2013 to 2015.

The 2017 edition of Healthgrades’ annual “ Report to the Nation” analyzes variation in clinical performance at 4,500 acute-care hospitals. It also advises consumers on their proximity to top-rated facilities and suggests they consider driving farther to hospitals with better demonstrated outcomes—especially if they are at higher risk for complications.  

The 19th annual report compares the predicted level of risk for complications and mortality to actual outcomes. Hospitals whose outcomes were statistically significantly above expected norms were given a five-star rating, those who performed as expected were given a three-star rating, and those with higher-than-predicted complication rates received a one-star rating.

Team Approach

Three high-performing hospitals were highlighted in the report with short profiles looking at their quality-improvement efforts, such as Bon Secours St. Francis Health System in Greenville, S.C.’s “Joint Camp” program, which includes preoperative education and post-operative surgery; Virginia Mason Medical Center in Seattle’s use of a four-part checklist to prepare patients for surgery; and the Hospital for Special Surgery in New York City’s use of perioperative physicians to manage patient’s chronic conditions that could raise concerns during their hospitalization.

The report quotes Catherine MacLean, MD, chief value medical officer at the Hospital for Special Surgery, who noted how high-quality care “is the result of thoughtful care delivery that is focused on the unique needs of individual patients that must be coordinated across a multidisciplinary team with skill sets to address each need.”

This team approach is what sets the five-star hospitals apart from the rest, according to Evan Marks, chief strategy officer at Healthgrades.

“The complication rate for knee surgery is 6.5 percent, so 93.5 percent walk out without a problem,” Marks said in an interview. “It’s not just the outcome of whether the knee is OK, it’s the management of other health issues. You need to treat the entire patient not just the knee.”

The risk factors for an 80-year-old diabetic with chronic obstructive pulmonary disease having knee surgery are higher than those for a healthy 50-year-old having the same procedure done, Marks said.

“There are kidney issues and cardiovascular issues that come into play, it’s these other things that will trip you up,” Marks said. “It’s often not the specific surgeries that you’re coming in for that are driving mortality and complications.”

Calculating Patient Risk

To help patients calculate their personal risk level, Healthgrades developed its risk IQ tool. Consumers can input their personal data and assess their risk for coronary artery bypass graft, pacemaker procedures, hip replacement, total knee replacement, hysterectomy and bariatric surgery. It was noted in the report that, while it may be urgent that these procedures be performed, consumers often have time to conduct research and make an informed choice about where they want to have theirs done.

This is where providing the geographic information comes into play, Marks said.

“For most healthy patients, ‘expected performance’ is sufficient,” Marks said. But there can be wide variation in care between hospitals in a specific market, so it makes sense to drive farther than consumers may have previously considered in order to receive care at a facility with lower complication and mortality rates, if your risk is higher.

The report highlighted how patients having a knee replaced at a five-star hospital had a 67 percent lower risk of complications and death than if they had it done at a one-star hospital. For bypass surgery, the difference was 86 percent, and for hip replacement it was 73 percent.

Nancy Foster, vice president for quality and patient safety at the American Hospital Association, thought the risk IQ tool was a positive step for patient engagement, but was a little skeptical of its clinical reliability.

Foster said in an interview that she pretended to be a knee-replacement patient and noted she was considered “low risk” when she listed herself as being of normal weight, but shot up to “high risk” when she added 20 pounds to her profile.

Foster also had issues with the advice on travelling farther to have a procedure done, noting that this could “impose significant burden” on patients--especially if they are advised to go to a hospital not covered by their insurance plan.

“That seems to be a missing ingredient here,” Foster said.

Reputation Not Measured

The report assessed complication and mortality rates for 32 common conditions and procedures using 2013 to 2015 data from the Medicare Provider Analysis and Review ( MEDPAR) and recent all-payer data from 18 states for appendectomy and bariatric surgery.

The Healthgrades methodology was praised as “relevant and objective” in a news release by Marcia Russell, MD, an assistant professor for surgery at the University of California at Los Angeles David Geffen School of Medicine. Using risk-adjusted Medicare inpatient mortality and complication data results in “leaving perception and reputation out of the rating equation.”

One result of this was that many hospitals receiving a five-star rating from the Centers for Medicare and Medicaid Services were rated lower by Healthgrades.

“I think it’s interesting their definition of a high performing-hospital is inconsistent with CMS’s,” Foster said. She added that subjective assessments of a hospital’s reputation in hospital rankings can be valuable.

“Well done assessments of hospitals done by experts in the field--heart surgeons judging the performance of other heart surgeons, for example—Is something worth paying attention to,” Foster said. “It’s part of painting the whole picture.”

Marks said “evaluating hospitals is objective,” and he singled out the Mayo Clinic in Rochester, Minn., as a high-profile institution that scored well with Healthgrades’ methodology.

“They do exceptionally well—especially for all the different cohorts,” Marks said. “If you look at some of the other more famous hospitals, they do well in some areas, but worse in others.”

He credited Mayo’s approach of managing surgical patients’ care as a “team sport” as the reason behind their high ratings.

“It’s not necessarily the individual surgeon’s expertise at Hospital X over Hospital Y,” Marks said. “It is the team.”


Andis Robeznieks is a freelance writer based in Chicago. Follow Andis on Twitter at @AndisRobeznieks.

Publication Date: Friday, October 21, 2016