Seriously sick kids need expertise that can't be found at most hospitals, where all but a few inpatients are adults. Children, as a popular medical school saying goes, aren't small adults. They are more vulnerable to infections because their immune systems aren't fully developed. They respond to medications faster and are more sensitive to too high or too low a dose. Their treatment may be much different than for an adult with the same condition. Moreover, kids are smaller; operating on walnut-sized hearts and starting IVs in veins that make spaghetti look big are only two of the challenges that pediatric specialists face day in and day out.
Best Children's Hospitals focuses on medical centers whose young patients come with cancer, cystic fibrosis, defective hearts, and other life-threatening, rare, or demanding conditions. The 2012-13 rankings showcase the top 50* children's centers in each of 10 specialties: cancer, cardiology and heart surgery, diabetes and endocrinology, gastroenterology, neonatology, nephrology, neurology and neurosurgery, orthopedics, pulmonology, and urology.
In all, 80 different hospitals ranked in at least one specialty this year. The Honor Roll recognizes 12 hospitals with high scores in at least three specialties.
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Many ranked hospitals are physically separate, freestanding children's hospitals. Most of the rest are large, multispecialty pediatric departments of major medical centers that function almost as if they were separate—essentially a hospital within a hospital—with their own staffs, operating rooms, and other facilities.
Ranking children's hospitals poses unique challenges. There is no pediatric equivalent of the enormous government-run Medicare files that U.S. News mines for much of the data poured into the annual Best Hospitals adult rankings. Children's hospitals are still thrashing out standards describing the kinds of data that should be collected to determine quality of care and how to analyze the information. The health reform law requires development of such performance standards, but it is likely to take several years for pediatric versions to take shape.
So U.S. News has reached out directly to the hospitals. Since 2007, when quality-related data was first added to the rankings, children's hospitals have been asked to fill out a lengthy online clinical survey—95 screens' worth for the 2012-13 rankings. Most of the 178 facilities surveyed for the new rankings are members of the Children's Hospital Association and fit the description of standalone centers or a hospital within a hospital. A small number of specialty and non-CHA hospitals that were previously ranked or recommended by trusted sources were added. Hospitals also had to verify that they had at least one of certain crucial kinds of physicians to be eligible in a specialty. To rank in cancer, for example, a hospital had to indicate fulltime coverage by at least one physician who is board-certified as a pediatric hematologist-oncologist.
Some survey questions, such as nursing data and the extent and success of programs that prevent infection, touched on all 10 specialties. Others, such as the rate of complications from kidney biopsies and five-year survival rates for several types of cancer, were specialty-specific. The latest survey was updated and enhanced with the help of 125 medical directors, department chairs, infection specialists, and other experts, grouped into specialty-related task forces. RTI International, a large North Carolina research and consulting firm that also generates the Best Hospitals rankings, reviewed the recommendations, directed the survey, and analyzed the results. One hundred hospitals turned in the survey.
Whether and how high a hospital was ranked depended on its showing in three areas: clinical outcomes such as cancer survival; the process of care, which included a hospital's national reputation among pediatric specialists and its compliance with "best practices" and steps to control infection; and adequacy of care-related indicators of quality such as patient volume, degree of nurse staffing, and availability of specialized programs.
The outcomes and care-related indicators were made up of scores of fine-grained measures, listed in the glossary. How we analyzed the data and put it together is fully described in the Best Children's Hospitals Methodology Report, a viewable and downloadable PDF file. Here are the basics of the three major components, each of which counted as one-third of a hospital's score:
Outcomes. Nothing matters more than outcomes—keeping kids alive, protecting them from infections and surgical complications, and improve the quality of life of those with chronic conditions. More research and better data collection and analysis have boosted the amount and reliability of outcome-related information that goes into the rankings. This year's additions, for example, include a measure of bloodstream infections caused by urinary catheters. Other kinds of data evaluate survival from various childhood cancers and from a complicated, multistage heart surgery, rates of bloodstream infection in intensive care units, and successful management of chronic conditions like asthma and cystic fibrosis.
Process of care. Previously, the process component meant one thing: a hospital's reputational score, based on a random survey of 150 board-certified pediatric physicians per specialty who were asked to name the five best hospitals in their area of expertise for children with serious or difficult medical problems, without considering location or expense. A hospital's score was the average of the most recent three years of survey responses.
To reputation we have now added several elements. One is a hospital's compliance with widely endorsed "best practices" such as conducting morbidity and mortality conferences to discuss unanticipated deaths or complications. A second is commitment to infection control through measures such as having a specialized "infection preventionist" on staff and tracking the correct use of antibiotics prior to surgery to prevent postop infections.
We have also changed how reputation is factored into a hospital's final score to reduce the tendency of high-reputation hospitals to outrank hospitals that, despite lower reputation scores, have records of significantly stronger performance on outcomes and other measures. The weight of reputation hasn't changed. It is still 25 percent of a hospital's overall 0-100 score. But how much of that 25 percent is credited to a hospital now depends entirely on the hospital's own reputational score. If it was nominated by 50 percent of the surveyed physicians, it receives 50 percent of 25 percent in the final score, or 12.5 "points."
This differs in two ways from past years. Before, the hospital with the highest reputational score in a specialty got the entire 25 percent (25 points in its final score) no matter how many or how few physicians nominated it, and the credit to other hospitals was scaled down accordingly. In this standard statistical practice, called normalization, hospitals got whatever part of 25 points corresponded to their reputational score times the top hospital's. If the top-scoring hospital had a reputational score of 75 percent and the next hospital got 45 percent, hospital No. 2 got 45 percent times 75 percent as its share of 25 percent, or 15 points in the final score.
In the revised methodology, however, a top-scoring hospital with a 75 percent reputational score receives 75 percent of the full 25 percent, or 18.75 points. A hospital with a 45 percent reputational score gets 45 percent times 25 percent, or 11.25 points in the final score. Last year's 10-point difference would narrow to 7.5 points.
More than 54 percent of the surveyed physicians submitted responses, a three-point increase from last year's already extremely high rate for such a survey.
Mix of care-related indicators. Surgical volume, nurse-patient ratio, and condition-specific clinics and programs are a few examples of an assortment of 38 measures, many with numerous submeasures, that were used across the 10 specialties.
*Editor's Note, 6/14/2012: Following publication, programming errors were discovered that produced misrankings of some hospitals in seven specialties. The rankings have been corrected and, for five specialties, extended beyond the top 50 to either 51 or 52. For more information including how the rankings changed, get details here.
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