New England Section of the American Urological Association

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Chasing the Pack: Association Between Urology Hospital Rankings and Surgical Outcomes
Alejandro Abello, MD, Michael Leapman, MD, Patrick A. Kenney, MD
Yale School of Medicine, New Haven, CT

INTRODUCTION AND OBJECTIVE: Patients value hospital rankings when making decisions about their healthcare. Rankings, such as the U.S. News and World Report (USNWR) integrate safety, outcome, and reputation metrics, however it is unknown whether these rankings are robust to surgery type, or if meaningful differences exist within top performing strata. Therefore, we aimed to study the associations of USNWR ranking and outcome measures using national registry data.
METHODS: We used the Vizient clinical database, a hospital registry representing care at 97% of academic medical centers and over six million inpatient visit submissions, to analyze outcomes for urologic surgeries from 2014 through 2018. We compiled the following hospital outcomes on mortality, length of stay (LOS), 30-day readmissions, LOS index (observed/expected ratios), case mix index and patient safety and adverse event composite (PSI-90) for radical prostatectomy (RP), cystectomy (RC) and radical nephrectomy (RN). We studied the associations of USNWR "Top 50 Hospitals" and outcome by surgery type and in aggregate. In addition, we examined the relative differences in outcome and rank order within quintiles of ranking.
RESULTS: We identified a total of 20,888 including 8,385 RP, 7,486 of RN and 5,017 of RC during the study period. Case volume was significantly higher in the top 10 hospitals for RP, RC, and RN compared to 11-20 that were the second group with highest volume (1,700 more cases for RP, 1,806 for RN and 490 for RC; P <0.001). Hospital LOS was significantly lower in the upper quintile for RP (P <0.001) and RN (P <0.001) but not in RC. Adjusting for expected ratios, LOS index was not different in RP among the different tiers but was lower for RN. 30-day readmission in upper quintile was significantly lower in RP only compared to 41-50 but similar to 11-40 institutions There was not significant variation in mortality between groups or procedures. Bottom ranking positions were negatively correlated with surgical volume (RP rho: -0.50, P<0.001; RN rho -0.41, P 0.005; RC rho: -0.42, P 0.0013) and positively correlated with mean LOS for RP (rho 0.45, P 0.002) and RC (rho 0.48, P 0.001). No other significant differences were found for the other variables. Comparing outcomes individually by hospitals, no significant differences or trends were found favoring top hospitals for LOS, mortality, costs, readmissions or PSI-90.
CONCLUSION
USNWR ranking of top urology programs was associated with better measures of patient outcome including mortality, readmission, and length of stay when grouped by quintiles and remained consistent across major cancer surgery types. There were no significant differences in outcome within deciles of rank, suggesting that categories of performance rather than ordinal position may be sufficient to describe hospital quality.


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