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Study: Wide Variation in Hospital Quality

What are the chances that your local hospital will deliver good care? According to a new study, it depends on where you live, the characteristics of your hospital, and the condition for which you are treated.

Data on the quality of care in health plans have been available for more than a decade, but until recently there has not been similar information on the quality of hospital care. Using data reported to the Centers for Medicare and Medicaid Services (CMS) under the Hospital Quality Alliance (HQA)—the first initiative to routinely report information on hospital performance nationally—Commonwealth Fund–supported researchers have now been able to see how hospitals measure up. They found that the quality of hospital care varies widely—not only by geographic region and type of hospital, but also across conditions within the same hospital.

In Care in U.S. Hospitals–The Hospital Quality Alliance Program (New England Journal of Medicine, July 21, 2005), researchers at the Harvard School of Public Health and Brigham and Women's Hospital examined HQA data from 2004. They looked at 10 measures that reflect quality of care for three major clinical conditions: acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. The indicators included administering aspirin within 24 hours of arriving at the hospital, use of an ACE inhibitor, and pneumococcal vaccination. For each of the 10 measures, a hospital's score reflects the proportion of patients who satisfied the criterion.

Quality differences among geographic regions were substantial. For example, the top-ranked region with respect to pneumonia, Oklahoma City, had a score of 82 percent, while the lowest-ranked region, San Bernardino, Calif., scored 59 percent. The gaps were smaller between the top- and bottom-ranked AMI and CHF performers. Boston ranked highest on both measures, while San Bernardino scored lowest on AMI and Lexington, Ky., scored lowest on CHF.

The Top- and Bottom-Ranked Performers Among the 40 Largest Hospital-Referral Regions

Acute Myocardial InfarctionCongestive Heart FailurePneumonia
Top-RankedScore (%)Top-RankedScore (%)Top-RankedScore (%)

Boston, Mass.95Boston, Mass.89Oklahoma City, Okla.82
Minneapolis, Minn.94Detroit, Mich.88Indianapolis, Ind.79
Kansas City, Mo.94Baltimore, Md.87Kansas City, Mo.78
Albany, N.Y.93Camden, N.J.87Camden, N.J.78
Indianapolis, Ind.92Cleveland, Ohio86Knoxville, Tenn.77

Bottom-ranked Bottom-ranked Bottom-ranked
Little Rock, Ark.86San Diego, Calif.77Miami, Fla.63
Orlando, Fla.86Nashville, Tenn.76Chicago, Ill.61
Miami, Fla.85Orlando, Fla.74San Diego, Calif.60
Memphis, Tenn.84Little Rock, Ark.69Los Angeles, Calif.60
San Bernardino, Calif.83Lexington, Ky.68San Bernardino, Calif.59

Source: A. K. Jha, Z Li, E. J Orav, and A. M. Epstein. "Care in U.S. Hospitals—The Hospital Quality Alliance Program," New England Journal of Medicine 353 (July 21, 2005): 265–74.


Performance scores also varied by condition. Seventy-three percent of hospitals that were in the top decile of AMI performance also were in the top quartile of CHF performance. However, only 33 percent of hospitals in the top decile of AMI performance were in the top quartile of pneumonia performance, and 41 percent were in the bottom half.

Academic hospitals had higher performance scores for AMI and CHF than nonacademic hospitals, but lower scores for pneumonia. The differences were modest, but statistically significant. Nonprofit hospitals also had somewhat higher scores for all three conditions than for-profit hospitals. Regional differences were considerable, with the Midwest and Northeast outperforming the West and South.

Clearly, quality of care varies greatly from hospital to hospital, and does not seem to be consistent even within hospitals for different conditions. "These data do not provide support for the notion that 'good' hospitals are easy to identify or consistent in their performance across conditions," say the study's authors. Data-collection efforts should be expanded to include more conditions, they argue, while quality improvement programs should focus on a larger number of hospitals.

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