OUR METHODOLOGY

Our Analysis

Methodology Paper

See our detailed methodology for how we created each metric, grade, and ranking for the Lown Hospitals Index.

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The Lown Index ranking for Social Responsibility

The Lown Index ranking for Social Responsibility is based on hospitals’ grades in equity, value, and outcomes. The Index includes up to 54 metrics to provide a unique and holistic ranking of hospital performance.

 

Equity

The equity grade combines assessments of community benefit spending, pay equity, and inclusivity to evaluate hospitals’ commitment to community health and civic leadership. Pay equity, community benefit, and inclusivity were weighted at 20%, 40%, and 40% respectively, to create the overall equity grade.

PAY EQUITY

The pay equity component measures the difference in compensation of hospital executives compared to housekeeping workers at hospitals.

We obtained data for Chief Executive Officer (CEO) compensation from three different sources: the Securities and Exchange Commission’s (SEC) database, public payroll data, and IRS 990 filings from fiscal year ending 2021. When CEO pay was unavailable, this information was imputed (estimated) using known values in regression models. For hospitals within systems (two or more hospitals), we distributed the system CEO’s salary among the constituent hospitals using the percentage of total revenue each hospital generated.

We obtained average housekeeping wages from the CMS Healthcare Cost Report Information System (HCRIS). We included both housekeeping and housekeeping under contract wage categories in our review, deferring to the category which had the higher total hours logged. For hospitals that had no housekeeping wage incomplete wage index information in HCRIS for 2020-2022, we substituted an average of housekeeping HCRIS wage index data from hospitals in the same state and with the same urban or rural status. We then estimated hourly wages for CEOs based on the work hours listed in their IRS forms, defaulting to 46.69 when the hours were not listed (the average hours worked among hospital CEOs), and calculated a ratio of CEO pay to average worker pay. Four hospitals were not ranked due to missing HCRIS data.

Value of Care

The value of care category reflects hospitals' avoidance of unnecessary care and ability to achieve good outcomes without overspending. The value category is based on two components, avoiding overuse and cost efficiency, weighed 40% and 60%, respectively, to create the overall value grade.

AVOIDING OVERUSE

Overuse (also known in the clinical community as low-value care) is the delivery of healthcare services that are more likely to harm than benefit the patient. The component comprises overuse rates of 12 common low-value tests and procedures, chosen based on their validation in previous research on measuring overuse. Hospitals’ overuse score for each service is based on the rate of overuse as well as the volume of overuse. For the overuse composite ranking, more weight placed on the services that make up the larger share of overuse.

To create this metric, we used Medicare claims data from January 1, 2019 – December 31, 2022. We included Medicare fee-for-service claims for 2020-2022 and Medicare Advantage claims for 2019-2021, the most recent time periods available.

For Acute Care Hospitals, we ranked hospitals on all 12 services (see below). Acute Care Hospitals with data available for six or more services were ranked on avoiding overuse. Critical Access Hospitals were ranked on carotid artery imaging for fainting and head imaging for fainting, as these services had adequate volume for most critical access hospitals. Critical Access hospitals with data for both of these services were given an avoiding overuse ranking.

Low-value tests and services:

Arthroscopic knee surgery – Surgery to remove damaged cartilage or bone in the knee using an arthroscope (tiny camera). Defined as overuse for patients with osteoarthritis or “runner’s knee” (damaged cartilage). Excluding patients with meniscal tears. Only Acute Care hospitals are ranked on this measure.

Carotid artery imaging for fainting – A test to screen for carotid (neck) artery disease. Considered overuse for patients where syncope (fainting) is the primary diagnosis, and there is no history of syncope in the past two years. Excluding patients with stroke or mini-stroke, retinal vascular occlusion/ischemia, or nervous and musculoskeletal symptoms. Both critical access and Acute Care hospitals are ranked on this measure.

Carotid endarterectomy – Procedure to remove plaque buildup from a carotid (neck) artery in a patient to prevent stroke. Considered overuse when performed on female patients without stroke symptoms or history of stroke. Only Acute Care hospitals are ranked on this measure.

Colonoscopy screening – Test for asymptomatic colorectal cancer. Defined as overuse for patients over 85 years old or performed more than once in a nine year period. Excluding patients with symptoms of colorectal cancer and patients at high risk of colorectal cancer. Only Acute Care hospitals are ranked on this measure.

Coronary artery stenting – Also known as percutaneous coronary intervention. Procedure to place a stent or balloon in a coronary artery using a catheter. Also includes procedures where the artery is opened but a stent is not inserted. Defined as overuse when performed on patients with stable heart disease (not having a heart attack or unstable angina). Excluding patients with past diagnosis of unstable angina. Only Acute Care hospitals are ranked on this measure.

EEG for fainting – A test of the electrical activity of the brain. Considered overuse for patients where syncope (fainting) is the primary diagnosis, and there is no history of syncope in the past two years. Only Acute Care hospitals are ranked on this measure.

EEG for headache – A test of the electrical activity of the brain. Defined as overuse for patients with headache as the primary diagnosis on the claim and no history of headache in the past two years. Excluding patients with epilepsy and recurrent seizures, convulsions, and abnormal involuntary movements. Only Acute Care hospitals are ranked on this measure.

Head imaging for fainting – Considered overuse for patients where syncope (fainting) is the primary diagnosis, and there is no history of syncope in the past two years. Excluding patients with epilepsy or convulsions, cerebrovascular diseases, head or face trauma, altered mental status, nervous and musculoskeletal system symptoms, and history of stroke. Both Critical Access and Acute Care hospitals are ranked on this measure.

Inferior Vena Cava (IVC) filter – Procedure to place a filter (a medical device) in the large vein in the abdomen to prevent blood clots from moving to the lungs. Considered overuse for all patients except those with history of multiple pulmonary embolism. Only Acute Care hospitals are ranked on this measure.

Renal artery stenting – Procedure to place a stent or balloon in the renal (kidney) artery. Considered overuse for patients with high blood pressure or plaque buildup in the artery. Excluding patients that had diagnosis of fibromuscular dysplasia of the renal artery (abnormal twisting of the blood vessels). Only Acute Care hospitals are ranked on this measure.

Spinal fusion/laminectomy – Procedure to fuse vertebrae together (spinal fusion) or remove part of a vertebra (laminectomy). Defined as overuse for patients with low-back pain, excluding patients with radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain or scoliosis. Only Acute Care hospitals are ranked on this measure.

Vertebroplasty – Procedure to inject cement into the vertebrae to relieve pain from spinal fractures. Considered overuse for patients with spinal fractures caused by osteoporosis. Excluding patients with bone cancer, myeloma, or hemangioma. Only Acute Care hospitals are ranked on this measure.

Patient Outcomes

The patient outcomes category reflects a hospital's performance as it relates to their patients' health and experience of care. This category is calculated from three components: clinical outcomes, patient safety, and patient satisfaction. Critical Access Hospitals were not ranked on patient safety due to lack of data. For Acute Care hospitals, the components were weighted as such: clinical outcomes (62.5%), patient safety (25%), and patient satisfaction (12.5%). For Critical Access hospitals, clinical outcomes was weighted 83.3% and patient satisfaction was weighted 16.7%.

CLINICAL OUTCOMES

The clinical outcomes component measures how well the hospital keeps patients alive and prevents return trips to the hospital, over various periods of time. All of the measurement and results for Acute Care and Critical Access Hospitals was performed separately on the split populations. For mortality and readmissions metrics, hospitalizations with probable or confirmed COVID-19 were excluded.

Using Medicare claims, we evaluated hospital clinical outcomes based on mortality and readmissions. We included Medicare fee-for-service claims for 2020-2022 and Medicare Advantage claims for 2019-2021, the most recent time periods available. The clinical outcomes metric is composed of risk-standardized rates of mortality and readmission, weighted at 80% and 20% respectively.

Mortality included rates of in-hospital, 30-day, and 90-day mortality. We chose these mortality endpoints to cover measurements in CMS' inpatient quality reporting programs as well as more extended periods when mortality is a function of both hospital and community. We also included risk-standardized rates of 7- and 30-day readmission, to include both a shorter interval that would reflect inpatient care quality, and longer follow-up that would reflect post-hospital community support.

New to the Lown Index in 2024 is unplanned hospital visits post outpatient surgery within 7 days, which includes inpatient admissions directly following surgery as well as any ED visit, observation stay, or unplanned inpatient admission following discharge from the hospital outpatient department (defined using CMS’s unplanned admission algorithm). We do not report unplanned hospital visits post outpatient surgery for Critical Access Hospitals, as the majority of these hospitals do not have high outpatient volumes.

Mortality, readmissions, and unplanned hospital visit rates rates were risk adjusted using the Risk Stratification Index (RSI), a Lown Institute-specific version of a machine-learning algorithm in the public domain that has been validated on multiple national, state-based, and hospital-based datasets. RSI has been shown to predict outcomes with greater discriminatory accuracy compared with other publicly available risk adjustment tools, by adjusting outcomes for numerous patient conditions and procedures. This allows us to better compare outcomes across patients that have the same medical needs. In addition to the patient conditions in RSI, we accounted for differences in hospital volume, patient risk, Medicare/Medicaid dual-eligibility rates, and types of services performed.

Pritpal Tamber
Consultant
Community Power and Health

THESE RANKINGS PROVIDE A MUCH-NEEDED AND LONG-OVERDUE FRAME THROUGH WHICH TO TRULY JUDGE THE VALUE OF OUR HOSPITALS."

Why this matters

People's lives depend on hospitals are making the right decisions. Let’s make sure they are guided by the most relevant tools possible, tools that measure what matters.