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'Five star' hospitals often provide fewer services than other hospitals, new data suggests

June 12, 2019

If you're looking for a top-notch hospital with a wide range of services, narrowing your list to hospitals with a five-star patient experience rating might lead you astray. Many five-star hospitals offer fewer services than those without five stars, according to a new study by Johns Hopkins researchers published June 10 in JAMA Internal Medicine.

"If you stay in a hotel with a five-star rating, you generally accept not only better service than in other hotels, but more services, from valet parking and room service to a spa and pool," says Zishan Siddiqui, M.D., assistant professor of medicine at the Johns Hopkins University School of Medicine and first author of the new paper. "But when it comes to hospitals, the five-star category is much less helpful at capturing the services offered."

The U.S. Centers for Medicare & Medicaid Services (CMS) publically reports data on more than 4,000 hospitals across the country. In the past, raw numbers -- reflecting measures such as patient satisfaction, complication rates and timeliness of care -- were published on the CMS website. In 2016, however, the agency debuted a system in which hospitals are assigned a star rating in several categories, including "patient experiences."

Although data on how the public uses the ratings isn't available, Siddiqui and his colleagues assume that people use them when choosing a facility for their medical care.

"If people are coming in with the same expectations as they have for five-star hotels when they review hospital star ratings, we wondered whether their expectations about getting more services in a five-star hospital would be true," says Siddiqui.

The researchers linked CMS patient experience star ratings with information from the American Hospital Association on the clinical services a hospital offers. Among 2,798 hospitals with patient experience star ratings, 150 hospitals (5.4%) received five stars. The team compared those hospitals to ones that received one through four stars in patient experience.

While 95.3% of most hospitals have emergency departments and 90.6% have intensive care units, only 77.3% of five-star hospitals have emergency departments and only 42.0% have intensive care units. Similarly, five-star hospitals are less likely to have neurology, cardiology, obstetrics and oncology units, among other services. Only 1.7% of five-star hospitals have neonatal intensive care units, compared to 31.5% of other hospitals. The five-star hospitals are also less likely to be teaching hospitals or research hospitals. Even when the team removed specialty hospitals -- such as cardiac and orthopaedic hospitals -- from the analysis, the results were similar: Five-star-rated general medical hospitals offered fewer services than general medical hospitals with lower ratings.

Siddiqui says the findings didn't surprise him. "These patient experience scores are based on the communication and responsiveness of health care workers," he explains. "When a hospital has generally healthy patients who all have a similar set of problems, it's much easier for physicians and nurses to communicate with them and respond to their needs."

Hospitals that have more services -- and therefore more complex patients -- have more challenges predicting patients' needs and are more likely to end up with low scores when patients are surveyed.

"This means hospitals that are seeing these kinds of patients are taking a hit when it comes to their rating," says Siddiqui. But those very hospitals -- with expertise in managing many types of patients -- may be those that people are looking for in a hospital search.

The findings don't necessarily apply to the other star ratings that CMS issues, since the current study only looked at patient experience star ratings. And Siddiqui says the ratings still have value -- a hospital with a four-star patient experience rating will generally have higher standards of communication and responsiveness than one with a one-star rating. But he hopes consumers take the ratings with a grain of salt and look beyond five-star hospitals when choosing their medical care.

"If you're looking for a hospital, I'd recommend using more than one evaluation method after narrowing hospitals based on your clinical needs, experience of family and friends with similar needs, word of mouth and your doctor's recommendation," he says.
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In addition to Zishan Siddiqui, authors on the JAMA Internal Medicine paper are Mohammed Abusamaan, Amanda Bertram, Lisa Allen, Albert Wu, Junya Zhu and Daniel Brotman, all of Johns Hopkins.

The authors received no financial support for the research and reported no conflicts of interest.

Johns Hopkins Medicine

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