Among the many organizations that rate hospitals and medical care—CMS, JCAHO, and Consumer Reports, to name a few—one that has captured the public’s attention since 1990 is the US News & World Report (USNWR) annual list of best hospitals, which includes its “honor roll” of the 15 very best. Yet, emergency medicine (EM) has never been included among the ranked specialties, raising the question, should the “best hospitals” have the best EDs?
Formerly a weekly newsmagazine and now web-based, USNWR still publishes print editions of its popular annual best colleges and best hospitals listings. Widely read and widely reported in other media, the lists appear to resonate strongly with the public, as well as with college and hospital administrators. But what exactly is meant by best? In a press release accompanying its 2015-16 best hospitals list, USNWR describes the purpose of the list as “designed to help patients with life threatening or rare conditions identify hospitals that excel in treating the most difficult cases,” and its honor roll as a list that “highlights hospitals that are exceptional in 16 specialties” (http://www.usnews.com/info/blogs/press-room/2015/07/21/us-news-releases-201516-best-hospitals). Specialties not included, in addition to EM, are internal medicine and surgery, which are represented by subspecialties, or service lines. The ranked list includes cardiology and heart surgery; diabetes and endocrinology; gastroenterology and GI surgery; geriatrics; nephrology; neurology and neurosurgery; pulmonology; rheumatology; and urology. Presumably, like medicine and surgery, EM is too all-encompassing a discipline, but unlike the case for the other two specialties, the need for emergency care in most locations does not allow patients to select the “best” facility for their acute problem. Nevertheless, it is interesting to speculate about the effect inclusion of EM would have on the elite institutions vying for honor roll status, as well as on EM itself.
A July 15, 2015 report on USNWR methodology (http://www.usnews.com/pubfiles/BH2015-16MethodologyReport.pdf) (http://www.usnews.com/info/blogs/press-room/2015/07/21/us-news-releases-201516-best-hospitals) notes that rankings in 12 of the 16 specialties are based on data-driven analyses of volume; technology and other resources (derived principally from the American Hospital Association annual survey); reputation for developing and sustaining the delivery of high-quality care (derived from surveyed physicians); and outcomes-based mostly on CMS risk-adjusted mortality figures. Rankings in the remaining four specialties are based solely on physician surveys of hospital reputation. Hospitals eligible for inclusion on the best hospitals list must either be teaching hospitals, be affiliated with medical schools, or, generally, have 200 or more beds.
Most, if not all, of these criteria can be applied to ranking EDs, but would doing so provide a valid assessment of the best EDs, and if so, to what end? The first question is too complicated to answer here. As for the second, many have argued that the “best ED” isn’t a relevant concept, considering that standards of emergency care demanded of every ED and emergency physician by ABEM, ACEP, ABMS, JCAHO, and more recently, CMS, have been promulgated and implemented nationwide for over three-and-a-half decades. But for the select few hospitals competing for the title of “best,” inclusion of EM among ranked specialties would send a very powerful message and require increased resources to achieve and maintain top standing. Even if EM is not ranked as a discrete specialty, many of the features of a “best ED” can and should be included. Currently, hospitals receive 1 point for being a state-certified, level 1 or level 2 trauma center. Points for other ED “center” designations could also be applied to a hospital’s overall score.
In any case, should USNWR include EM in future best hospitals listings, perhaps many of the measures that will be taken by hospitals to claim the title of “best ED” could subsequently become standard operating procedure for all EDs. So, let the games begin.
*“News You Can Use” is a column that ran in USNWR beginning in 1952.