Nephrology and the US News and World Report Hospital-Based Specialty Rankings

On July 27, 2021, US News and World Report (USNWR) published its annual “Best Hospitals” and specialties rankings for 2021-2022. Notably, the USNWR removed nephrology as a ranked specialty (Box 1).1Olmsted M.G. Powell R. Murphy J. et al.Methodology - U.S. news & world report 2021-22 best hospitals: specialty rankings. Research Triangle Institute International.https://health.usnews.com/media/best-hospitals/BH_Methodology_2021-22Google Scholar This significant, first-time instance of dropping a major specialty established a barrier for 37 million Americans living with kidney diseases. Often part of historically disadvantaged populations with low levels of awareness of their conditions,2Chu C.D. Chen M.H. McCulloh C.E. et al.Patient awareness of CKD: a systematic review and meta-analysis of patient-oriented questions and study setting.Kidney Med. 2021; 3: 576-585Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar patients with kidney diseases now cannot access information to guide nephrology care decisions. The USNWR did not provide a clear rationale for the change. A new USNWR “procedure and condition” of “kidney failure” was added (defined by the International Classification of Diseases, Tenth Revision, diagnosis of acute kidney failure), and reference was made to overlap with hospital admissions previously attributed to nephrology.3Adams Z. Lu K. Seo M.H. et al.Methodology - U.S. news & world report 2021-22 best hospitals: procedures & conditions ratings. U.S. News & World Report.https://health.usnews.com/media/best-hospitals/BHPC-Methodology-2021-2022Google Scholar Unfortunately, “kidney failure” (with a ranking scale of high performing, average, or below average; Box 2) does not adequately capture nephrology care and is confusing to patients.Box 1US News and World Report Nephrology Ranking Before 2022. Abbreviation: AHA, American Hospital Association.Best hospitals, nephrology based on total specialty score (12 characteristics) Rank, Hospital, Total Specialty Score1.30-day survival2.Discharging patients to home3.Patient experience4.Number of patients5.Nurse staffing6.Intensivists7.Advanced technologies8.Patient services9.Trauma center10.Recognized as nurse magnet hospital11.Expert opinion12.Current AHA responderBox 2US News and World Report Kidney Failure Ranking 2022Kidney Failure ScorecardA hospital’s kidney failure score is based on multiple data categories, including patient survival, volume, and more. Over 6,000 hospitals were evaluated and eligible hospitals received one of three ratings – high performing (1,089 hospitals), average (1,403 hospitals), or below average (999 hospitals) with the balance either not offering the service or performing too few of the procedures to be rated. Hospitals that earned a high performing rating were significantly better than the national average. Find nephrologists near you. See more hospitals ratings in Kidney Failure.Overall Kidney Failure ScoreRating: Below Average Best hospitals, nephrology based on total specialty score (12 characteristics) Rank, Hospital, Total Specialty Score1.30-day survival2.Discharging patients to home3.Patient experience4.Number of patients5.Nurse staffing6.Intensivists7.Advanced technologies8.Patient services9.Trauma center10.Recognized as nurse magnet hospital11.Expert opinion12.Current AHA responder Kidney Failure Scorecard A hospital’s kidney failure score is based on multiple data categories, including patient survival, volume, and more. Over 6,000 hospitals were evaluated and eligible hospitals received one of three ratings – high performing (1,089 hospitals), average (1,403 hospitals), or below average (999 hospitals) with the balance either not offering the service or performing too few of the procedures to be rated. Hospitals that earned a high performing rating were significantly better than the national average. Find nephrologists near you. See more hospitals ratings in Kidney Failure. Overall Kidney Failure Score Rating: Below Average The absence of hospital-based nephrology care rankings stands in stark contrast to rankings for other prevalent, complicated conditions such as cancer and cardiovascular disease. As a team of a patient advocate and 2 nephrologists, we represent others who are concerned about the USNWR’s decision to remove nephrology as a ranked specialty. Although the United States strives to advance policies to enhance awareness of kidney disease, transform patient-centered kidney care, and improve health equity, the USNWR’s decision hinders these important efforts, impacting vulnerable patient populations at the risk of and living with kidney diseases. The USNWR ranks hospitals and hospital specialties, and although there are methodologic challenges, it provides an important source of information for patients. Hospital rankings are calculated by aggregating specialty performance. As of 2022, there were 3 reputation-only specialties, as determined based on Doximity survey data, and 12 data-driven specialties. The components of the data-driven specialties include the following: 1) Doximity reputation data (27.5%); 2) Medicare claims-based outcomes such as 30-day survival after admission (30%) and discharging patients for home after hospitalization (7.5%); 3) data on patient experience from Hospital Consumer Assessment of Healthcare Providers and Systems (5%); 4) American Hospital Association annual survey data on structural measures (such as hospital volume and nurse staffing); and 5) for certain specialties, public transparency as defined by data sharing in specialty-specific registries. The USNWR’s hospital-based rankings have been criticized for reliance on reputation and limitations in mortality methodology.4Sehgal A.R. The role of reputation in U.S. News & World Report’s rankings of the top 50 American hospitals.Ann Intern Med. 2010; 152: 521-525Crossref PubMed Google Scholar, 5Mendu M.L. Kachalia A. Eappen S. U.S. News & WorldRevisiting US News & World Report’s Hospital Rankings-Moving Beyond Mortality to Metrics that Improve Care.J Gen Intern Med. 2021; 36: 209-210Crossref PubMed Scopus (3) Google Scholar, 6Harder B. Comarow A. Hospital quality reporting by U.S. News & World Report: why, how, and what’s ahead.JAMA. 2015; 313: 1903-1904Crossref PubMed Scopus (17) Google Scholar Given that the USNWR relies on an online physician networking platform, Doximity, for collection of reputational data, the survey process is limited to physicians using the platform. The mortality methodology relies on attribution of deaths to a given specialty based on Medicare Severity-Diagnosis Related Groups. However, this approach can result in mortalities being attributed to a specialty despite patients not being cared for by that specialty.5Mendu M.L. Kachalia A. Eappen S. U.S. News & WorldRevisiting US News & World Report’s Hospital Rankings-Moving Beyond Mortality to Metrics that Improve Care.J Gen Intern Med. 2021; 36: 209-210Crossref PubMed Scopus (3) Google Scholar The USNWR’s current approach to risk adjustment for mortality calculations is based on an Elixhauser regression model that is not transparent, limited to potentially incomplete diagnosis capture, and challenging to understand. Because of lack of accountability, independent researchers cannot verify whether the methodology adequately accounts for the severity of illness for patients at the end of their life. The USNWR does acknowledge imperfect claims data and unadjusted confounding.6Harder B. Comarow A. Hospital quality reporting by U.S. News & World Report: why, how, and what’s ahead.JAMA. 2015; 313: 1903-1904Crossref PubMed Scopus (17) Google Scholar Significant opportunities exist for improvement of all data that the USNWR use to rank hospitals, such as broadening patient experience measures, incorporating safety measures, and including health equity metrics. Notwithstanding imperfections, USNWR rankings are used by patients to make decisions and by hospitals for direct-to-consumer advertising.7Larson R.J. Schwartz L.M. Woloshin S. Welch H.G. Advertising by academic medical centers.Arch Intern Med. 2005; 165: 645-651Crossref PubMed Scopus (59) Google Scholar Recently, several law and medical schools withdrew from participating in the USNWR’s annual processes for ranking these institutions.8University of Chicago, Washington University Med Schools The Latest To Exit U.S. News Rankings. Forbes Magazine. Accessed February 8, 2023. https://www.forbes.com/sites/michaeltnietzel/2023/01/27/u-of-chicago-washington-university-med-schools-the-latest-to-exit-us-news-rankings/?sh=3bd3f982200eGoogle Scholar This exodus is largely a result of concerns about the quality of the USNWR’s process, data, and rankings as well as concerns about perpetuating inequities in graduate education. However, participation in the USNWR’s hospital rankings, which are not based on self-reported data by hospitals, continues to be unaffected by graduate schools’ decision making. Although reputation is subjective, many patients would still be interested in understanding the following: “where would expert nephrologists want to receive kidney care?” Furthermore, the incorporation of patient experience and structural measures captures other patients’ past experiences and hospital resources. Therefore, the USNWR’s specialty rankings offer foundational information for patients about where to receive specialty-specific care. Depriving people living with kidney diseases of this information should not be taken lightly. Disadvantaged people are overrepresented among Americans living with kidney diseases, with stark disparities in clinical outcomes.9Nicholas S.B. Kalantar-Zadeh K. Norris K.C. Socioeconomic disparities in chronic kidney disease.Adv Chronic Kidney Dis. 2015; 22: 6-15Abstract Full Text Full Text PDF PubMed Google Scholar Hispanic and Black patients with kidney diseases have a 2.2-4.0-fold higher risk of progression to kidney failure and an elevated risk of acute kidney injury compared with White patients. Patients with housing insecurity, lack of insurance, and a low income have a higher risk of kidney failure or death. Myriad factors are thought to contribute to these historical disparities, including social determinants of health, access to care, patient awareness, and distrust of the medical system. The USNWR’s decision will perpetuate and further exacerbate already-steep inequities in information faced by disadvantaged patients compared with that in other patient groups with larger networks and greater financial resources, who are better able to identify the best providers in the absence of published information. Promoting awareness is fundamental to empowering and engaging patients about care delivery. Unfortunately, by focusing on kidney failure instead of kidney health, the USNWR’s rankings contradict the spirit of national initiatives supported by the US Department of Health and Human Services, American Society of Nephrology (ASN), and National Kidney Foundation to promote such awareness. Improving transparency about hospital care delivery would raise awareness, result in greater patient engagement, and empower patients to advocate for their own health.10Goodridge D. Isinger T. Rotter T. Patient family advisors’ perspectives on engagement in health-care quality improvement initiatives: power and partnership.Health Expect. 2018; 21: 379-386Crossref PubMed Scopus (15) Google Scholar Patient survey data support quality reporting of specialty care at the hospital level in particular.11John I.J. Choo H. Pettengell C.J. Riga C.V. Martin G.F. Bicknell C.D. Patient views on surgeon-specific outcome reporting in vascular surgery.Ann Surg. 2021; 274: e1030-e1037Crossref PubMed Scopus (2) Google Scholar Although other public reporting tools exist (such as that at www.medicare.gov/care-compare), they can be challenging to navigate, limiting their use, unlike USNWR, which has a wide lay audience readership as well as marketing by hospitals and their parent institutions. In addition, rankings can motivate hospitals’ kidney centers to provide higher-quality care. Fostering patient awareness, coupled with transparency about perceived and objective quality of care, is essential for advancing patient empowerment. Moving forward, the USNWR can and should reinstate nephrology as a ranked specialty. Not doing so is irresponsible and could lead to worse care for more than 37 million Americans, with the largest burden borne by minoritized populations and those living in disadvantaged communities. Like other patient groups, people living with kidney diseases are entitled to access information that can guide decision making on where to receive care. USNWR leaders have navigated methodologic complexities for similar specialties, even smaller ones, and can take comparable approaches for nephrology. For the past year, the ASN outlined varied methodologic changes that could be incorporated (www.asn-online.org/policy/webdocs/ASN.USNWR.pdf). These recommendations include the following: 1) incorporating patients with acute kidney injury on dialysis in the mortality methodology as a specific population managed by nephrologists; 2) incorporating patients with end-stage renal disease listed as a primary or secondary diagnosis, along with common diagnoses associated with end-stage renal disease-related hospitalizations (hypertension, heart failure, etc); 3) exploring the incorporation of patients with advanced chronic kidney disease and kidney transplants; and 4) exploring ambulatory populations, particularly patients with chronic kidney disease, hypertension, and transplant. We appreciate that these additional outcome measures may require further analysis and iteration before implementation. However, in the meantime, to ensure access to ranking information for patients, nephrology could be reinstated immediately as a reputation-only specialty, like rheumatology. As a team of a patient advocate and 2 nephrologists representing the broader kidney community, including the ASN and National Kidney Foundation, we advocate for ongoing improvements of the USNWR ranking system as well as other efforts to promote transparency. USNWR rankings can serve as a starting point for patients assessing the quality of nephrology care at a given hospital. It is incumbent on the kidney community, health systems, as well as federal and state governments to facilitate additional information sharing to guide decision making. People living with kidney diseases are entitled to the data afforded by USNWR rankings. By reconsidering their decision to remove nephrology from the hospital rankings, the USNWR will avoid stepping backward and, instead, move forward toward empowering patients with information about their care. Curtis Warfield, BS, MS, Eugene Lin, MD, MS, and Mallika L. Mendu, MD, MBA Dr Lin receives support from the National Institute of Diabetes and Digestive and Kidney Diseases (K08 DK118213 and R03 DK131239), American Society of Nephrology’s KidneyCure, and University Kidney Research Organization. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors declare that they have no relevant financial interests. We would like to thank Dr Sri Lekha Tummalapalli, Dr Susan E. Quaggin, Dr Crystal Gadegbeku, Tod Ibrahim, and David White for their important contributions to this article. Received January 23, 2023. Direct editorial input from the Editor-in-Chief. Accepted in revised form February 12, 2023.