US News now includes health equity in hospital rankings

This is according to a recent Viewpoint in JAMA from Binger, Chen and Harder (2022).

On July 26, 2022, US News & World Report published new and updated health equity measures for hospitals featured on the publication’s website…

Each equity measure was developed under a framework comprising 3 domains: access, outcomes, and social determinants of health. Analogous to the domains of the Donabedian model of quality, these represent areas in which hospitals have opportunities to promote equitable health. Measures in the access domain evaluate the extent to which vulnerable patient populations residing in the hospital’s community are able to make use of various health care services. The outcomes domain refers to whether the results of care differ between certain groups of patients. The social determinants of health domain examines ways in which hospitals address social conditions that create and exacerbate health inequities.

Example measures related to access include whether there are differences in the extent to which different races undergo elective procedures. Ensuring hospitals take individual preferences into consideration regardless of race is vitally important. However, there may be other factors–e.g., how generous an individual’s insurance plan is–which could also explain some differences in the rates of elective procedures. If there are differences in insurance generosity across races, that certainly would be one area of concern around health equity, but clearly hospitals cannot control the insurance coverage of its patients except perhaps by choosing the location of the hospital.

For outcomes, US News looks at hospital-level differences in the risk of 30-day unplanned readmission between visits for Black patients and White patients following coronary artery bypass graft surgery, knee replacement procedures, and spinal fusion surgery. This outcome measure does a good job of controlling for differences in outcomes by race, but US News must be sure to risk adjust to account for any differences in demographics, comorbidities or disease severity across races in the patients they treat.

For social determinants of health, US News looks at differences in contributions toward charity care for uninsured individuals, relative to the number of people uninsured in their community. This measure is probably the most problematic. It is not clear why hospitals should be rewarded based on charity care. A better alternative would be use policy to expand insurance coverage to more individuals rather than force hospitals into caring for patients without reimbursement. Further, even if the measure was valid, defining a “community” is not as easy as it seems. Is a community a neighborhood? City? County? Metropolitan Statistical Area? State? This may make a big difference as many large cities have significant heterogeneity in the rates of uninsured across different neighborhood. Whether or not you have a high vs. low number of uninsured individuals relative the community almost certainly depends on this definition.

In short, while I commend the US News for considering health equity in their rankings, making sure these measures are accurate, fair, actionable, and can be addressed by hospitals are also very important considerations.