Poor Ratings Linked to Hospitals in Distressed Neighborhoods

MedicalResearch.com Interview with:
Jianhui Hu, PhD

Center for Health Policy & Health Services Research
Henry Ford Health System
Detroit, Michigan

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: In July of 2016, the Center for Medicare and Medicaid services (CMS) released its first-ever hospital Star Rating for consumers to use to compare hospital quality. Since earlier studies have shown that hospitals serving lower-socioeconomic-status (SES) communities have lower scores on measures like readmission rate that are a part of the Star Rating system, we wanted to find out whether a similar relationship might be found between community-level SES and the Star Ratings. Our study used a recently released “stress” ranking of 150 most populated U.S cities and explored possible associations with the hospital Star Ratings. This “stress” ranking was a composite score of 27 individual metrics measuring a number of characteristics of the cities, such as job security, unemployment rate, housing affordability, poverty, mental health, physical activity, health condition, crime rate, etc.

Our study found that less-stressed cities had average higher hospital Star Ratings (and more-stressed cities had lower average hospital Star Ratings). Cities such as Detroit and Newark are good examples of those with high “stress” and relatively low hospital Star Ratings, and cities like Madison and Sioux Falls of those with relatively low stress and relatively high hospital Star Ratings. Our correlational analysis indicated that around 20% of the difference in the Star Ratings can be explained by characteristics of the cities in which hospitals were located.

MedicalResearch.com: What should readers take away from your report?

Response: A hospital’s location affects its Star Rating. Although it is possible that hospitals in stressed cities did provide lower average quality of care, it is also possible that level of resources in the community, such as poor public transportation system or lack of social support services, had an independent impact on patients’ outcomes and therefore affected the Star Ratings. To the extent that the latter is true, the Star Ratings would present a biased picture of hospital quality.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: Our study found an association between city characteristics and hospital Star Rating; it’s very important for the future studies to explore the underlying causal relationships. How much of the observed variation in measures of patient outcome is really due to hospital quality, and how much is it due to the influence of other factors that have nothing to do with hospital quality?

Additional analyses can also look at smaller geographic units. We know that within the boundary of a city there are very different sociodemographic sub-areas, and hospitals in the same city serve patient populations with very different sociodemographic characteristics. We would like to see future studies investigating the relationship using these further-refined and better-defined areas.

MedicalResearch.com: Is there anything else you would like to add?

Response: With the upcoming expansion of public quality reporting and pay-for-performance programs into the levels of physician, physician group, or clinic, similar questions will be brought up about the relationships between measures used in those programs and characteristics of the communities in which practices are located. If public reporting of quality measures is going to be used as a vehicle for consumer choice and quality improvement, we believe that the measures used should convey the most accurate, unbiased, and informative message possible about quality differences among providers.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.


Hu J, Nerenz D. Relationship Between Stress Rankings and the Overall Hospital Star Ratings An Analysis of 150 Cities in the United States. JAMA Intern Med. Published online November 28, 2016. doi:10.1001/jamainternmed.2016.7068
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