Shopping for a Hip Replacement in Florida? Go by the Numbers

Each year, nearly 300,000 people have one or both hips replaced. Most of the time the results are dramatically for the better, allowing patients to cast off pain and immobility. About one in 15 patients, however, suffers complications that can be severe, among them infection, nerve damage, blood clots, and failure of the implanted artificial joint, according to a 2010 report in the American Journal of Orthopedics. And these problems can be prevented. Some hospitals have consistently shorter stays, fewer complications and readmissions, and lower mortality than others do.

Data tell the story; data that are recent and decent can help patients make informed choices about where to get surgery. Yet few patients can look at these important statistics. Few hospitals reveal them, and most states don't publish hospital-specific data, often blaming tight budgets and pushback from local hospitals and doctors.

Florida is an exception. Its Agency for Health Care Administration (AHCA) posts charge, length of stay, readmissions, and mortality data on FloridaHealthFinder.gov. U.S. News decided to examine Florida hip-replacement data as part of a long-term project that will assess how well the nation's hospitals perform relatively routine procedures. In previous reports, we've examined heart surgery data from New York and Cesarean-section rates in Virginia. We hope to learn from states that are leading the way in informing the public about hospital performance.

Hip replacement makes a good case study. The operation may be routine, but it's far from trivial. The operation demands precision. Moreover, all artificial hip joints are not equal. If the surgeon chooses a device that's less than optimal—perhaps because he had a hand in its design—the patient may pay the price.

 Florida's data, from 2011, are unusually fresh, covering 184 hospitals that performed hip replacements last year. Hospitals must submit the data to AHCA as a licensing requirement. A contractor verifies the data, analyzes it, and returns it to the state for posting.

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*One star, higher than expected; two stars, as expected; three stars, lower than expected.

Statewide, 29,210 Florida residents were hospitalized for hip replacement surgery in 2011. They were in the hospital for an average of 4.3 days. Just under 5 percent were readmitted within 15 days of surgery. Nineteen patients died, an overall death rate of .06 percent. The state does not report rates of side effects, such as joint failure, blood clots, or infection.

But hospitalizations, length of stay, and readmissions begin to provide a picture of a hospital's efficiency and effectiveness. The state also reports hip-replacement mortality, which is so rare—most hospitals reported zero deaths—that the main value of the data lies in spotlighting the few exceptions.

Florida risk-adjusts its data sets in different ways. For readmission data, a proprietary approach from 3M is utilized; for mortality, a blend of ICD-9 codes and 3M APR-DRGs developed by the federal Agency for Healthcare Research and Quality is employed.

AHCA doesn't display all hip-replacement data together. Billed charges, length of stay, and readmissions are in one place; mortality data are separate, to rescue consumers from data overload. Each hospital gets two ratings: 1 to 3 stars for readmissions and 1 to 3 stars for mortality, with 1 star denoting the worst performers and 3 the best.

Only three of the state's 184 hospitals received the best-possible 3 stars for readmissions: West Marion Community Hospital in Ocala with a rate of 1.0 percent, Broward Health North in Pompano Beach with 1.7 percent, and Holy Cross Hospital in Fort Lauderdale with 2.8 percent. All three hospitals replaced lots of hips in 2011, ranging from 483 at West Marion to 571 at Broward Health North.

At the other end of the spectrum, 17 hospitals performed poorly, with risk-adjusted readmissions ranging from 7.2 percent at JFK Medical Center in Atlantis, where doctors performed 446 hip replacements in 2011, to 13.8 percent in Wuesthoff Medical Center in Melbourne, where doctors did just 44. No official body has established a recommended minimum for the number of annual hip replacements a hospital should perform, but nine of the 17 poor performers did 100 or more procedures in 2011. Hip replacement volume at Florida hospitals varied dramatically, from 32 procedures at Pasco Regional Medical Center in Dade City, with a rate of 7.7 percent, to 667 at Morton Plant Hospital in Clearwater, with a rate of 3.7 percent.

None of the hospitals had significantly fewer deaths than expected. That is no surprise, since most of them had no deaths at all. Four hospitals, however, got a single star for a higher death rate than expected: Orange Park Medical Center in Orange Park, Winter Haven Medical Center in Winter Haven, St. Mary's Medical Center in West Palm Beach, and Broward Health Imperial Point in Fort Lauderdale. None of the hospitals had more than a single death, but their patients presented such low risk that one death was enough to significantly boost the risk-adjusted mortality. Interestingly, all of these hospitals got two stars for readmissions, within the expected range for the state.

For U.S. News, two separate star ratings for one procedure may be too many. It asks a lot of prospective patients to consider the merits of two ratings, each with its own methodology. Our inclination favors a composite score. But would that unfairly penalize a hospital that performs well overall but reports a death? Are these datapoints sufficient, moreover, to draw conclusions about hospital performance? Shouldn't patients be informed about complications and patient safety issues, from infections to blood clots to hip failure?

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