For most patients who need hospitalization, the one the doctor recommends probably is fine — but it might not be if you need demanding surgery or if age, physical infirmities or a chronic condition could compromise your treatment or procedure. Then a visit to the Best Hospitals national rankings and Best Regional Hospitals rankings may be in order. What goes into those evaluations, as well as questions of interest to media and health care professionals, are addressed in this FAQ.
Where can I find the rankings?
- The Best Hospitals Honor Roll highlights the top 18 hospitals in America.
- The national rankings name the top hospitals in each of 16 specialties.
- The regional rankings reveal which hospitals are best in each city or state.
Why does U.S. News rank hospitals?
Every year, as many as 2 million hospital patients face surgery or care that is technically challenging or a risk of death or harm that is multiplied because of age, physical condition or infirmities. The rankings provide such patients with a tool to help them find unusually skilled inpatient care.
What's an example of a patient like this?
Take a man in his 90s who needs a faulty heart valve replaced. Most hospitals would decline to perform the procedure (as they should if they aren't up to speed on the special techniques and precautions required and don't see many such cases) or, worse, they might operate even if they lacked the skills, subjecting the man to great risk. A hospital that appears in the Best Hospitals rankings in cardiology and heart surgery is likely to have the necessary experience and expertise.
How are the rankings organized and updated?
The Best Hospitals rankings, which are updated every July, are grouped into 16 individual specialty lists. Twelve of the 16 showcase the 50 top-scoring hospitals, based mostly on death rates for the most demanding cases, patient safety and other categories of performance that can be weighed with hard data. An annual reputational survey of physicians, who are asked to name hospitals they consider the best in their specialty for difficult cases, also is factored in. While unranked nationally, hospitals with scores that fell within the top 25 percent of the range in a given specialty are recognized as high-performing in the specialty. A hospital that is either ranked or high-performing in at least one specialty is further recognized as among the Best Regional Hospitals within its state and metro area or similar region. (More on the Best Regional Hospitals methodology below.)
In four other specialties, hospitals are ranked by reputation alone based on the three most recent annual physician surveys. Those receiving nominations from at least 5 percent of the specialists who responded to the last three surveys are nationally ranked Best Hospitals. Those nominated by at least 3 percent but less than 5 percent of physicians are high-performing Best Regional Hospitals.
Hospitals that rank very high in at least six specialties are recognized in the Honor Roll. (See below, "What is the significance of the Honor Roll?")
What are the 16 specialties in which hospitals are ranked?
The 12 data-dependent specialties are cancer; cardiology & heart surgery; diabetes & endocrinology; ear, nose & throat; gastroenterology & GI (gastrointestinal) surgery; geriatrics; gynecology; nephrology; neurology & neurosurgery; orthopedics; pulmonology, and urology.
The four reputation-only specialties are ophthalmology, psychiatry, rehabilitation and rheumatology.
Are the highest-ranked hospitals in a specialty the best choice?
Not necessarily. Each specialty ranking evaluates hospitals according to their performance across a wide range of conditions and procedures. In pulmonology, for example, one hospital might rank lower than another overall but outperform it in treating patients with a particular condition, such as chronic obstructive pulmonary disease (COPD).
So the rankings are just a starting point?
Yes. Patients have to do their own research. We also appreciate that families also have to consider the stress and expense of traveling to another city, as well as the willingness of an insurer to pay for care at a hospital outside its network.
How many hospitals were analyzed for the 2013-14 rankings? Were teaching hospitals the only ones considered?
For the 12 data-driven rankings, we started with virtually all nonfederal community hospitals in the U.S. of any size, a universe that comprised 4,806 hospitals. (We would be delighted to include military and VA hospitals but have been unsuccessful in persuading the federal government to release the necessary data.)
It is not true, as is often proclaimed by "experts" even in the professional literature, that we only look at teaching hospitals. From the starting pool of 4,806, a hospital had to meet any of four possible criteria to qualify for consideration in the data-driven specialties: teaching-hospital status, medical school affiliation, bed size of 200 or more, or bed size of 100 or more plus availability of four or more specific types of medical technology such as a PET/CT scanner and certain precise radiation therapies. This year 2,262 hospitals, or 47 percent of the initial number, met the test.
In the four specialties in which ranking was determined only through the physician survey, even meeting this test was not required. Any hospital with enough nominations over the last three surveys was ranked.
How many hospitals were ranked or regional high performers?
Across all 16 specialties, only 147 U.S. hospitals performed well enough to be nationally ranked in one or more specialties. Another 591 were regional high performers. Just 18 qualified for a spot on the Honor Roll by ranking at or near the top in six or more specialties (more on the Honor Roll below).
What was the process following the initial screening?
Hospitals next had to show that they treated enough patients to be eligible for specialty ranking. The required volume varied by specialty. The threshold was a certain number of Medicare inpatients discharged from 2009 to 2011 who had had certain specialty-related procedures and conditions, each at a specifically defined level of severity and complexity. The threshold for gastroenterology & GI surgery, for example, was 561 patients, 151 of whom had to be surgical cases. For pulmonology the total was 968 with no required surgical minimum. A hospital that fell short still could make it through the gate if nominated by at least 1 percent of the physicians in a specialty who responded to the 2011, 2012 and 2013 reputational surveys. That left a total of 1,894 hospitals eligible in at least one specialty.
What determined whether a hospital was ranked?
We examined the performance of each hospital through the lens of various categories of data. Some of the statistics came from the federal Centers for Medicare & Medicaid Services' MedPAR data base. Other information came from the American Hospital Association and professional organizations. The connection with quality and safety is evident for some of the statistics used, such as death rates. For other categories, such as the number of patients and the balance of nurses and patients, the link may be less obvious but is nevertheless supported by ample research. The physician survey also played a role, though it accounted for less than a third of each hospital's score (more on that below).
In the four reputational specialties, most care is delivered on an outpatient basis, and so few patients die that mortality data, which carry heavy weight in the 12 other specialties, mean little. Hospitals therefore are ranked solely based on reputation.
How were the different factors combined?
Each candidate in the 12 data-driven rankings received an overall score from 0 to 100 that was based on four elements: reputation, patient survival, patient safety, and care-related factors such as the amount of nurse staffing and the breadth of patient services. The hospitals with the top 50 scores in each specialty were ranked. Scores and data for all eligible hospitals in each specialty are also posted. The four elements and their weightings, in brief:
Reputation with specialists (32.5 percent). Each year, 200 physicians per specialty are randomly selected and asked to list the hospitals they consider to be the best in their specialty for complex or difficult cases. The figure displayed is the average percentage of responding specialists in 2011, 2012 and 2013 who named the hospitals. A statistical adjustment is made to keep a small number of hospitals with very high reputational scores from swamping the rest of the field in the final rankings. The adjustment allows hospitals with low reputational scores but strong clinical numbers to outrank centers with higher reputations. Many hospitals in the rankings have very low and even zero reputational scores.
Survival (32.5 percent). A hospital's success at keeping patients alive was judged by comparing the number of Medicare inpatients with certain conditions who died within 30 days of admission in 2009, 2010 and 2011 with the number expected to die given the severity of illness. Hospitals were scored from 1 to 10, with 10 indicating the highest survival rate relative to other hospitals and 1 the lowest rate. Software used by many researchers (3M Health Information Systems Medicare Severity Grouper) took each patient's condition into account.
Patient safety (5 percent). Harmful blunders occur at every hospital; this score reflects how hard a hospital works to prevent six of the most egregious types. Injuries during surgery and major bleeding afterwards are two examples of the six categories of medical mishaps that were factored in. A hospital among the top 25 percent in this regard earned a score of 3, those in the middle 50 percent scored a 2, and those in the lower quartile scored a 1.
Other care-related indicators (30 percent). These include nurse staffing, patient volume, certain clinically proven technologies and other measures related to quality of care. The American Hospital Association's 2011 survey of all hospitals in the nation was the main source.
In the four specialties where rank relies only on reputation, ranked hospitals had to be cited by a total of at least 5 percent of the physicians in a specialty who responded to the most recent three years of U.S. News surveys. That resulted in lists 16 hospitals long in ophthalmology and psychiatry and 17 long in rehabilitation and rheumatology.
Were there changes in the 2013-14 Best Hospital methodology?
Two that are worth noting (and were first noted in this Second Opinion column). A revised version of a programming tool created by the federal Agency for Healthcare Research and Quality to assess safety-related hospital data enabled us to exclude patients from the patient-safety calculation who were admitted to the hospital with conditions that predisposed them to harm. That kept a hospital from being penalized if someone still recovering from pneumonia, for example, was admitted for surgery and had respiratory problems afterwards. (Postsurgical respiratory failure is one of the six categories of events we tabulate.)
Extracting these present-on-admission cases, or POAs, from the case mix boosted patient safety scores for hospitals where such cases had previously exacted a penalty. Some hospitals achieved higher overall scores as a result and rose in the rankings, or displaced ranked hospitals that had been less affected by POAs and therefore gained less from the methodology change. Taking advantage of the POA exclusion requires hospitals to be diligent about identifying such patients and coding them appropriately. Hospitals that do not diagnose all POAs or that code them inaccurately not only derive no benefit from the change, but are penalized relative to hospitals that do better.
The other significant Best Hospitals change only affected hospitals in neurology & neurosurgery. Spinal fusion procedures ceased to be counted in this specialty. Hospitals and health care experts told us that, because of recent clinical trends neurologists and neurosurgeons now play a minimal role in recommending and performing the procedures. Spinal fusion cases this year counted only in orthopedics, where they were also included in past years.
How does U.S. News decide what changes to make to its methodology?
Each year RTI International, a large North Carolina-based research and consulting firm, revisits the methodology based on the medical literature and input from hospitals and discusses possible changes with U.S. News. Any changes are implemented only with U.S. News approval.
What is the significance of the Honor Roll?
It recognizes the small number of hospitals that are unusually competent across a range of specialties, not just one or two. High ranking in a minimum of six specialties is required. In the 12 specialties that used objective data, a hospital had to be ranked in the top 20 to receive Honor Roll credit; in the reputation-only specialties, a hospital had to be ranked in the top 10. In addition to Honor Roll credit, points were awarded. A hospital earned two points if it ranked among the top 10 in a data specialty and one point if ranked from 11 through 20. In the reputational specialties, a hospital got two points if in the top 5 and one point if ranked from six through 10. The order of the Honor Roll was based first on total points, with ties broken by the number of specialties. No hospital ranked first in every specialty.
Where can more detailed information be found?
A complete description of the data analysis is available as a viewable and downloadable PDF, the 2013-14 Best Hospitals Methodology Report.
What is a high-performing hospital?
To be high performing, a hospital had to have a score that placed it among the top 25 percent of eligible facilities in at least one specialty, using the same methodology that identifies nationally ranked Best Hospitals. In four other specialties in which rank is based on a reputational survey of physician specialists, a hospital had to be named by an average of 3 percent or more of responding physicians over the latest three years of surveys. A hospital that met the standard is recognized as a high-performing hospital.
How are high-performing hospitals recognized?
U.S. News recognizes Best Regional Hospitals at three geographic levels: states, regions and metro areas.
States. Regional high performers are recognized in their respective states. They are also ranked, in those states with two or more such hospitals and at least one of them either nationally ranked in at least one specialty or high-performing in at least four specialties. Alaska, Nevada and Wyoming did not meet these criteria for 2013-14, so the small number of high-performing hospitals in those states, while recognized as Best Regional Hospitals, are not ranked numerically.
Except in those three states, each hospital’s state rank is determined by the number of specialties in which it is either nationally ranked or high-performing; a hospital that is nationally ranked in more specialties than another hospital in the same state receives a better state rank. When two or more hospitals have an equal number of specialties in which each is nationally ranked, the hospital that’s high performing in a greater number of specialties receives the better state rank. When two or more hospitals in a state have the same number of nationally ranked specialties as well as the same number of high-performing specialties, they receive the same state rank – that is, they are tied. The same logic is used to determine hospitals’ metro rank, in those metro areas that meet the criteria described below.
Regions. Counties and county equivalents, such as parishes, are grouped into approximately 200 regions that reflect geography, local custom and regional health care markets. High-performers are recognized in these regions. However, they are not numerically ranked in the region unless the region is a metro area that meets the criteria below.
Metropolitan areas. Hospitals are evaluated in 100 metro areas with populations of 500,000 or more in the 2010 Census. Hospitals recognized in 2013-14 are located in the 94 metro areas listed on our Best Regionals map. Hospitals are rank ordered within a metro area, if it has a population of 1 million or more and meets the standards described above for state ranking.
In three cases, U.S. News departed from the U.S. Census Bureau list of Metropolitan Statistical Areas to use the somewhat larger Combined Statistical Areas. This permits nearby smaller cities with nationally ranked hospitals to be included. They are Detroit (adding Ann Arbor), Raleigh-Cary, N.C. (adding Durham and Chapel Hill and renaming the expanded area Raleigh-Durham), and Salt Lake City (adding Ogden). Some metropolitan areas cross state lines.
Are high-performing hospitals in regions outside major metro areas ranked?
What changes were made in the 2013-14 regional methodology?
We sometimes evaluate two separate hospitals as a unit when they function as a single facility in a specialty. In 2012-13, each hospital in such a pair was eligible for state or metro area ranking when the combined unit was nationally ranked or recognized as high performing. For 2013-14 that is no longer the case. In orthopedics and rheumatology, for example, the Hospital for Joint Diseases and NYU Langone Medical Center were a combined, nationally ranked entity in 2012-13 but were separately ranked in New York state and the New York metropolitan area. In the 2013-14 regional rankings, the contribution of a specialized hospital like the Hospital for Joint Diseases to a larger hospital's ranking was noted but the specialty facility does not appear in the state or metro rankings even if it is nationally ranked in a specialty.
Can I find out what cities and towns are included in a region?
Yes — email your request to Health-PR@usnews.com.
How can I find a listing of all the Best Regional Hospitals in a particular region?
To see all Best Regional Hospitals in a state, click on the name of the state on http://health.usnews.com/best-hospitals/area or enter the state name in a search. One more click will take users to a list of all Best Regional Hospitals for any U.S. News-recognized region within that state.
Why aren't children's hospitals ranked in metro areas?
Even most large metro areas have just one or two Best Children's Hospitals, making health care consumers' decision about where to go for pediatric care simpler than for adult care. Ranking very small numbers of children's hospitals within a metro area wouldn't offer meaningful assistance. A Best Children's Hospitals FAQ and downloadable report with full methodology details are available.
How many high-performing hospitals are there in each specialty?
The following numbers include nationally ranked hospitals, since they made up part of the top 25 percent in the 12 data-dependent specialties and were nominated by more than 3 percent of surveyed physicians in the four reputational specialties: cancer (227), cardiology & heart surgery (180), diabetes & endocrinology (286), ear, nose & throat (173), gastroenterology & GI surgery (394), geriatrics (389), gynecology (282), nephrology (418), neurology & neurosurgery (347), ophthalmology (21), orthopedics (415), psychiatry (35), pulmonology (424), rehabilitation (26), rheumatology (26) and urology (377).
Clarification 8/6/13: This story has been updated to clarify the rules by which hospitals’ state and metro area rankings are determined.