What It Takes To Be The Best

For most people most of the time, the hospital their doctor recommends is fine — the majority of hospital care is fairly routine.

That's not a word normally associated with hospitalization, but consider this: In 2005, the latest year for which figures are available, fewer than 6 percent of hospital visits—including those for surgery—necessitated even an overnight stay.

Compare that with 7 percent in 1995 and 13 percent in 1985. Besides, many community hospitals are perfectly capable of performing operations formerly reserved for elite medical centers. Going to a hometown hospital means being close to family and friends, whose watchfulness might keep things from going wrong. And patients draw strength from their comforting presence.

A local hospital shouldn't always be the default choice, however. Many community hospitals cannot legitimately claim to be highly competent, to name just a few tough challenges, in replacing an elderly woman's heart valve, diagnosing and treating a cancer of the neck, shoring up a weak spot in the aorta that threatens to rupture, or saving a leg with circulatory blockages from amputation.

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From admission to discharge, Dr. Bernadine Healy preps patients and their families for major surgery

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Centers of excellence. This year's "America's Best Hospitals" rankings cover 16 specialties, from cancer and heart disease to respiratory disorders and urology. (After a year's absence, geriatrics is back; pediatrics is not included, but only temporarily. It will return in the near future, revamped and expanded.) Hospitals are ranked by specialty and not by specific procedures because the goal is to identify facilities that excel at treating a variety of demanding illnesses and procedures within a specialty, not just a few.

Out of 5,462 hospitals evaluated, only 173 met that standard in one or more specialties. Most that did are referral centers, places accustomed to seeing the toughest patients and conducting bench-to-bedside research that advances the state of the art. We don't consider military and veterans hospitals, not by choice but because the federal government won't part with the necessary data. Of the 173 ranked hospitals, just 18 made the super elite Honor Roll. These are medical centers that scored at or near the top (at least 2 standard deviations above the mean) in a minimum of six specialties.

In 12 of the 16 specialties, a hospital's prowess is largely measured by hard data. In four others, ranking is determined solely by annual surveys of physician specialists, as explained in the "reputation" section below. Initial eligibility in the 12 data-driven specialties is based on meeting any of three standards: membership in the Council of Teaching Hospitals, affiliation with a medical school, or availability of at least six out of 13 advanced services such as image-guided radiation therapy and robotic surgery. This year, three quarters of all hospitals failed this first test.

Each specialty had its own eligibility requirements. A hospital either had to have seen a specified minimum number of Medicare inpatients during 2003, 2004, and 2005 who had certain conditions or underwent certain procedures—803 patients with a particular set of respiratory disorders, for example—or the facility had to be named among the best in the specialty by at least one physician in the latest three annual surveys.

Hospitals that got through the second gate then received a score combining three equally weighted elements: reputation, death rate, and care-related factors such as nursing and advanced services. The rankings consist of the 50 highest-scoring hospitals.

Here is how the three elements break down. More detail is available in the glossary.

Reputation. For each of the 16 specialties, a randomized sample of 200 board-certified specialists was selected from the American Medical Association's Masterfile of more than 850,000 U.S. doctors, and those physicians were mailed a survey form. They were asked to list the five hospitals they think are best in their specialty for difficult cases, without taking location or expense into account (or naming their own hospital). The numbers in the "reputation" column are the combined percentages of responding physicians in the 2005, 2006, and 2007 surveys who listed the hospitals. Nearly half of the 3,200 doctors surveyed this year responded.

Mortality index. What is more important than a hospital's ability to keep patients alive? The number shown is a ratio—a comparison of the number of deaths of Medicare inpatients with certain conditions that occurred with the number that was expected (after adjusting for severity of condition) during 2003, 2004, and 2005. An index number below 1.00 therefore means the hospital did better than expected; above 1.00 means worse than expected. Deaths were included if they occurred within 30 days from the date of admission except in cancer, in which only deaths from admission to discharge were included. Severity adjustments were derived from 3M Health Information Systems software (All Patient Refined Diagnosis Related Group).

Other care-related factors. The remaining third of the score reflects quality indicators such as patient volume, relative availability of nurses, advanced technology, and credentialing by professional bodies. Much of the information came from the American Hospital Association's 2005 survey of its members. This year, some measures were reorganized and placed in different categories.

Reputational specialties. The reason for ranking ophthalmology, psychiatry, rehabilitation, and rheumatology only by reputation is that mortality data are irrelevant or unreliable in these specialties. Ranked hospitals were cited by at least 3 percent of responding physicians.

By Avery Comarow