CMS star ratings do not fully represent procedure risks at low-volume facilities, HSS study finds

Practice Management

CMS’ Overall Hospital Quality Star Ratings program significantly understates complication risks for patients who undergo total joint arthroplasty at hospitals that perform relatively few TJAs, according to a study in The Journal of Bone & Joint Surgery.

Five things to know:

1. CMS launched the star ratings in July 2016 as part of an effort to promote value-based care. The program includes 57 performance measures in seven categories, encompassing mortality, patient safety, hospital readmission, effectiveness and timeliness of care and other factors in hospitalization. Hospitals can receive an overall rating between one and five stars.

2. While hospitals that perform a high volume of a particular procedure usually have better outcomes than low procedure-volume facilities, the star system does not include measures for hospitals that perform fewer than 25 but more than zero procedures over a three-year period.

3. The Hospital for Special Surgery researchers assessed four measures: complications and readmissions for TJA, and mortality and readmissions for coronary artery bypass grafting, for which high-volume hospitals tend to perform better than low-volume hospitals. The study authors used three methods to estimate values for the missing low-volume facilities from the public CMS database.

4. For three of the four measures, including the estimates did not affect overall ratings, suggesting that the star ratings do not reflect the volume-outcome relationship for those measures.

5. For complications after TJA, nearly 40 percent of hospitals had their score change once the estimates of the low-volume data were added to the model. Of those, roughly a third gained a star or more while two-thirds lost a star or more. "Overall, although low-volume hospitals were more often hurt than helped after imputation [of the missing, low-volume outcome measures] … higher-volume hospitals were also more often hurt than helped," the study authors wrote.

"As health-care incentives move toward value-based programs in which higher quality is rewarded financially, defining quality in relative terms may very well prevent some providers with high absolute quality scores, but lower relative quality scores, from achieving those rewards," the HSS researchers wrote. “This overemphasizing of differences, in turn, could engender counterproductive competition by discouraging hospitals from sharing best practices and collaborating."

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