Medicare Identifies Best and Worst Hospitals for Hip, Knee Replacements

Jordan Rau

December 19, 2013

Medicare has begun tracking the outcomes of hip and knee replacement surgeries, identifying 95 hospitals where elderly patients were more likely to suffer significant setbacks. The government also named 97 hospitals where patients tended to have the smoothest recoveries.

The analysis, which was released last week, is the latest part of the government's push to improve quality at the nation's hospitals instead of simply paying Medicare patients' bills. Medicare already assesses hospital death rates, how consistently hospitals follow basic medical guidelines and how patients rate their stays. The evaluation of hip and knee surgery outcomes is significant because for the first time, Medicare is rating hospitals' performance on two common elective procedures.

Many patients needing joint replacements want to know a hospital's record when choosing where to have the procedure done. This is not usually the case for treatment of conditions Medicare has evaluated previously, such as heart attacks.

Of the 95 hospitals where knee and hip surgery patients experienced difficulties after the operation, nine were rated having both high readmissions and high complication rates. Those hospitals were: Froedtert Hospital in Milwaukee; Grant Medical Center in Columbus, Ohio; Mercy St. Anne Hospital in Toledo, Ohio; Northwestern Memorial Hospital in Chicago; the Pennsylvania Hospital of the University of Pennsylvania Health System in Philadelphia; Peterson Regional Medical Center in Kerrville, Texas; Reston Hospital Center in Reston, Va.; Shannon Medical Center in San Angelo, Texas, and Southside Regional Medical Center in Petersburg, Va.

Some of those hospitals complained Monday that Medicare's assessments were outdated since they covered operations between July 2009 through June 2012. A spokeswoman for Shannon Medical Center said the hospital has improved since then, adding better technology and opening a clinic to follow up with patients seven days after leaving. A spokeswoman for Southside Regional Medical Center said that hospital adopted a new treatment model in 2012 for joint and spine patients and that their outcomes have "drastically improved."

Medicare was cautious in how it marked hospitals, only categorizing them as outliers when their records in hip and knee replacements were statistically different from the national average. The overwhelming majority of hospitals-about 19 out of 20-were branded average, a Kaiser Health News analysis found.

Out of the 97 hospitals that did better than average in avoiding either readmissions or complications, 25 were rated as being better at both measures. Those included some big hospitals such as Sutter General Hospital in Sacramento, Calif., and the Hospital for Special Surgery in Manhattan. They also included some local hospitals such Holy Cross Hospital in Fort Lauderdale, and several physician-owned hospitals that specialize in these types of surgeries, such as Arkansas Surgical Hospital in Little Rock.

About 600,000 patients in the traditional Medicare program have their hips or knees replaced each year. The growing popularity of these operations has made them a more significant expense for Medicare and private insurers. In 2010, there were 719,000 knee replacements costing nearly $12 billion and 332,000 hip replacements nearly $8 billion, according to the National Center for Health Statistics.

Medicare published the new outcomes data on its Hospital Compare website. While few consumers use that site, this information may reach a greater audience later on through groups and publications, such as Consumer Reports, that tap Medicare's data in devising their own hospital ratings.

"With elective procedures, consumers like to do a lot of research to pick the right doctor and the right hospital, so this is a good first step," said Leah Binder, CEO of the Leapfrog Group, a nonprofit funded by employers that judges hospital quality. However, she said the new ratings would be of limited use for most patients because the Centers for Medicare & Medicaid Services judged most hospitals' performance as normal.

"We know there's a significant variation among hospitals, but CMS reports them all as average," Binder said.

Financial Pressure

Hospitals may soon feel a financial pinch from the evaluations. Medicare plans to add hip and knee readmission rates to the criteria it uses when deciding whether to penalize hospitals each year.

Since October, Medicare has been paying less than it normally does to 2,225 hospitals after determining their rates of rebounds for patients with pneumonia, heart attacks and heart failure were too high, even by a small amount. Starting in the fall of 2014, when the joint replacements are to be factored into the penalty program, hospitals are at risk of losing as much as 3 percent of Medicare payments for each patient stay.

In its new evaluation of hip and knee replacement patients, Medicare used two measures. One was how often the patients ended up being readmitted to the hospital within 30 days of discharge. The other was how often they suffered one of eight complications after the operation. Those included a heart attack, pneumonia, sepsis or shock within seven days of admission. They also included bleeding at the site of the surgery, a blood clot in the lung or death within a month of admission. Medicare also counted mechanical complications with implants and infections of the joint or wound within 90 days of admission.

The quality of joint implants has been under scrutiny for several years. Some of the surgical devices have been plagued by quality problems, especially among artificial hips made of interlocking metal parts. The friction created by these joints can create metal debris that damages the surrounding flesh and bone. Two manufacturers have recalled their devices since 2010.

Problems Are Declining

Nationwide, the number of readmissions following hip and knee replacement surgeries has been dropping, but not as quickly as readmission rates for heart attack, heart failure or pneumonia patients, according to a Medicare-commissioned study by the Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation.

Dr. Eric Coleman, an expert on readmissions at the University of Colorado Anschutz Medical Campus, said some hospitals are trying to prevent joint replacement patients from returning by educating them ahead of the surgeries about how to take care of themselves and warning signs of problems. This program provides "a chance to walk you through what to expect, what your family would expect, how to arrange your home," Coleman said. "In most of the cases of readmission reductions, we're still very reactive."

Hospitals' clientele appears to play some role in how they fared after these surgeries. The outcomes for hip and knee replacements tend to be slightly worse for hospitals that serve a high proportion of Medicaid patients, according to the Yale study. The study also found that hospitals where more than one out of every five patients were African-American tended to have slightly higher complication and readmission rates than did hospitals with no black Medicare patients. However, the report noted, some of these hospitals serving large numbers of Medicaid or black patients also performed very well.

These kind of racial and economic disparities in readmissions have long troubled health policy experts. Some hospitals mostly cater to prosperous patients who have the money, resources and education to get necessary post-surgical care after discharge. But safety net hospitals often have a harder time ensuring that low-income, less educated people follow the often complex instructions about how to recover from a major surgery or hospitalization.

In Medicare's new analysis, on average, hip and knee patients had a 5.4 percent chance of having to return to the hospital. Nationally, the average complication rate for patients after hip and knee replacement surgery was 3.4 percent. One hospital, Beaumont Health System in Royal Oak, Mich., had a mixed record: Patients there were more likely to be readmitted but less likely to suffer serious complications.

Hospital-Wide Readmissions Published

The government also last week released its first ratings of how often Medicare patients of all diagnoses returned to hospitals within 30 days. That "all cause" measure is more encompassing than Medicare's appraisals based on heart attack, heart failure and pneumonia. A number of prominent experts, including Congress' Medicare Payment Advisory Commission, have been pushing for this measure to be used in setting financial penalties for hospitals.

Medicare's analysis found that 16 percent of Medicare patients ended up returning to a hospital within 30 days between July 2011 through June 2012. Again rates varied significantly. At 364 hospitals, or 8 percent, patients were more likely than average to return within a month, the data show. These included the Cleveland Clinic, as well as the clinic's hospital in Weston, Fla.; both of Johns Hopkins's hospitals in Baltimore; and New York-Presbyterian Hospital in Manhattan.

Medicare did not count cases where the patient was scheduled to return to the hospital, such as when a lung cancer patient was admitted for pneumonia and later came back for a chemotherapy treatment that had been planned. Medicare calculated that patients were less likely than average to end up back for any reason at 315 hospitals, or 7 percent of the nation's total.

Nancy Foster, an executive with the American Hospital Association, said that tracking hospital-wide readmissions was of limited value to hospitals that wanted to do better. "Most of the interventions you would use are built and targeted around particular conditions," she said. "You have to know what's driving patients back into the hospital to address the problem. When you get this lump of all-cause readmissions, you don't know what to go after."

Table: Hospitals Judged Best and Worst for Hip and Knee Readmissions and Complications

Hospital Name City State Readmission After Hip/Knee Surgery Comlications Following Hip/Knee Surgery
DCH Regional Medical Center Tuscaloosa AL -- Worse
Decatur Morgan Hospital-Decatur Campus Decatur AL -- Worse
Gadsden Regional Medical Center Gadsden AL -- Worse
Trinity Medical Center Birmingham AL -- Worse
Arkansas Surgical Hospital No. Little Rock AR Better Better
Saline Memorial Hospital Benton AR Worse --
White River Medical Center Batesville AR -- Worse
Scottsdale Healthcare-Shea Medical Center Scottsdale AZ Better --
Yavapai Regional Medical Center Prescott AZ -- Better
Community Memorial FElkHospital San Buenaventura Ventura CA -- Worse
Doctors Medical Center Modesto CA -- Worse
Eisenhower Medical Center Rancho Mirgage CA Better --
Enloe Medical Center Chico CA Worse --
Hoag Orthopedic Institute Irvine CA Better Better
Mercy Medical Center Redding Redding CA Better --
Saint John’s Health Center Santa Monica CA Better Better
Salinas Valley Memorial Hospital Salinas CA Better --
St. Helena Hospital Saint Helena CA -- Better
St. Joseph Hospital Orange CA -- Better
Sutter Auburn Faith Hospital Auburn CA -- Worse
Sutter General Hospital Sacramento CA Better Better
Torrance Memorial Medical Center Torrance CA -- Better
Washington Hospital Fremont CA Better Better
Medical Center of Aurora Aurora CO -- Worse
North Colorado Medical Center Greeley CO -- Worse
Poudre Valley Hospital Fort Collins CO Better Better
Swedish Medical Center Englewood CO -- Worse
Bridgeport Hospital Bridgeport CT -- Worse
St Francis Hospital and Medical Center Hartford CT -- Better
St Vincent’s Medical Center Bridgeport CT -- Worse
Providence Hospital Washington DC Worse --
Bayfront Medical Center Inc Saint Petersburg FL Worse --
Blake Medical Center Bradenton FL Better --
Boca Raton Regional Hospital Boca Raton FL Better --
Delray Medical Center Delray Beach FL -- Better
Florida Hospital Memorial Medical Center Daytona Beach FL -- Better
Heart of Florida Regional Medical Center Davenport FL Better Better
Holy Cross Hospital Inc Fort Lauderdale FL Better Better
Indian River Medical Center Vero Beach FL -- Better
Jupiter Medical Center Jupiter FL -- Better
Leesburg Regional Medical Center Leesburg FL Worse --
Ocala Regional Medical Center Ocala FL Better Better
Orlando Health Orlando FL Worse --
Sacred Heart Hospital Pensacola FL -- Better
South Lake Hospital Clermont FL -- Worse
St Joseph’s Hospital Tampa FL Worse --
St Vincent’s Medical Center Jacksonville FL -- Better
Tampa General Hospital Tampa FL -- Better
Emory University Hospital Atlanta GA Better --
Floyd Medical Center Rome GA -- Worse
Saint Joseph’s Hospital of Atlanta Inc Atlanta GA Better Better
St Joseph’s Hospital – Savannah Savannah GA -- Better
Alegent Health Mercy Hospital Council Bluffs IA -- Worse
Genesis Medical Center - Davenport Davenport IA -- Worse
Mercy Medical Center – Cedar Rapids Cedar Rapids IA Better --
Advocate Christ Hospital and Medical Center Oak Lawn IL Worse --
Advocate Good Samaritan Hospital Downers Grove IL Worse --
Evanston Hospital Evanston IL Better --
Galesburg Cottage Hospital Galesburg IL Worse --
Louis A Weiss Memorial Hospital Chicago IL -- Worse
Northwestern Memorial Hospital Chicago IL Worse Worse
Proctor Hospital Peoria IL -- Better
Riverside Medical Center Kankakee IL -- Better
St Alexius Medical Center Hoffman Estates IL -- Worse
Elkhart General Hospital Elkhart IL Better --
Franciscan St Elizabeth Health –Lafayette East Lafayette IL -- Better
Indiana Orthopaedic Hospital Indianapolis IL -- Better
Orthopaedic Hospital at Parkview North LLC Fort Wayne IL Better Better
Saint Joseph Regional Medical Center Mishawaka IL -- Better
St Vincent Anderson Regional Hospital Inc Anderson IL -- Worse
The Orthopaedic Hospital of Lutheran Health Network Fort Wayne IL Better --
Kansas Medical Center LLC Andover KS Better Better
Kansas Surgery and Recovery Center Wichita KS -- Better
Olathe Medical Center Olathe KS -- Better
Overland Park Regional Medical Center Overland Park KS -- Worse
University of Kansas Hospital Kansas City KS -- Worse
Baptist Health Louisville Louisville KY -- Better
Minden Medical Center Minden LA Worse --
Cape Cod Hospital Hyannis MA -- Better
New England Baptist Hospital Boston MA Better Better
Doctors’ Community Hospital Lanham MD Worse --
Saint Ages Hospital Baltimore MD Worse --
Shady Grove Adventist Hospital Rockville MD -- Worse
Sinai Hospital of Baltimore Baltimore MD Worse --
Western Maryland Regional Medical Center Cumberland MD -- Better
Central Maine Medical Center Lewiston ME -- Worse
Maine Medical Center Portland ME Better Better
Beaumont Health System Grosse Pointe MI -- Worse
Beaumont Health System Royal Oak MI Worse Better
Bronson Methodist Hospital Kalamazoo MI -- Better
Crittenton Hospital Medical Center Rochester MI -- Better
Genesys Regional Medical Center – Health Park Grand Blanc MI -- Worse
Mclaren – Greater Lansing Lansing MI -- Better
St Joseph Mercy Oakland Pontiac MI Better Better
William Beaumont Hospital Troy Troy MI -- Better
Mayo Clinic Methodist Hospital Rochester MN -- Better
Barnes Jewish Hospital Saint Louis MO -- Better
Boone Hospital Center Columbia MO -- Better
Des Peres Hospital Saint Louis MO Worse --
Heartland Regional Medical Center Saint Joseph MO Better Better
Mercy Hospital St Louis Saint Louis MO Worse --
North Kansas City Hospital North Kansas City MO -- Worse
Poplar Bluff Regional Medical Center Poplar Bluff MO -- Worse
Mississippi Baptist Medical Center Jackson MS -- Better
North Mississippi Medical Center Tupelo MS -- Better
South Central Regional Medical Center Laurel MS -- Worse
Kalispell Regional Medical Center Kalispell MT Better --
St Vincent Healthcare Billings MT -- Worse
Carolinas Medical Center-Northeast Concord NC -- Worse
Memorial Mission Hospital and Asheville Surgery Center Asheville NC Better Better
Onslow Memorial Hospital Jacksonville NC -- Worse
Park Ridge Health Hendersonville NC -- Worse
Rowan Regional Medical Center Salisbury NC -- Worse
Sanford Medical Center Bismarck Bismarck ND -- Better
Sanford Medical Center Fargo Fargo ND Better --
Nebraska Orthopaedic Hospital Omaha NE -- Better
Saint Elizabeth Regional Medical Center Lincoln NE Better Better
Wentworth-Douglass Hospital Dover NH -- Worse
Centrastate Medical Center Freehold NJ Worse --
Saint Michael’s Medical Center Inc Newark NJ -- Worse
Presbyterian Hospital Albuquerque NM Better --
Spring Valley Hospital Medical Center Las Vegas NV -- Worse
Community Memorial Hospital Inc Hamilton NY Better --
Hospital for Special Surgery New York NY Better Better
NYU Hospitals Center New York NY -- Worse
South Nassau Communities Hospital Oceanside NY -- Better
Southside Hospital Bay Shore NY -- Better
St Catherine of Sienna Hospital Smithtown NY -- Worse
St Peter’s Hospital Albany NY -- Better
United Health Services Hospital Johnson City NY Better --
Atrium Medical Center Franklin OH -- Worse
Defiance Regional Medical Center Defiance OH -- Worse
East Ohio Regional Hospital Martins Ferry OH -- Worse
Grant Medical Center Columbus OH Worse Worse
Kettering Medical Center Kettering OH Better --
Mercy St Anne Hospital Toledo OH Worse --
Samaritan Regional Health System Ashland OH Better Better
Southwest General Health Center Middleburg Heights OH -- Better
University of Toledo Medical Center Toledo OH -- Worse
Jackson County Memorial Hospital Altus OK Worse --
Oklahoma Surgical Hospital LLC Tulsa OK Better Better
St Anthony Hospital Oklahoma City OK -- Worse
Sacred Heart Medical Center – Riverbend Springfield OR Better --
Abington Memorial Hospital Abington PA Worse --
Lancaster General Hospital Lancaster PA -- Worse
Meadville Medical Center Meadville PA Better --
Penn Presbyterian Medical Center Philadelphia PA Worse --
Pennsylvania Hospital of the Univ of PA Philadelphia PA Worse Worse
Pinnacle Health Hospitals Harrisburg PA -- Worse
Reading Hospital Reading PA Better --
Riddle Memorial Hospital Media PA -- Worse
St Clair Memorial Hospital Pittsburgh PA -- Worse
St Luke’s Hospital Bethlehem Bethlehem PA -- Worse
Thomas Jefferson University Hospital Philadelphia PA Worse --
Beaufort County Memorial Hospital Beaufort SC Worse --
Roper Hospital Charleston SC -- Better
Baptist Memorial Hospital Memphis TN -- Worse
Henry County Medical Center Paris TN -- Worse
Johnson City Medical Center Johnson City TN -- Worse
Memorial Healthcare System Inc Chattanooga TN Better Better
Parkwest Medical Center Knoxville TN Worse --
Saint Thomas Midtown Hospital Nashville TN -- Better
St Thomas Hospital Nashville TN Better --
Wellmont Holston Valley Medical Center Kingsport TN Worse --
Baptist St Anthony’s Hospital Amarillo TX -- Worse
Christus Santa Rosa Hospital San Antonio TX Better --
Christus St Michael Health System Texarkana TX Worse --
Covenant Medical Center Lubbock TX -- Better
Doctors Hospital at Renaissance Edinburg TX -- Better
Grace Medical Center Lubbock TX Better --
Houston Orthopedic and Spine Hospital Bellaire TX -- Worse
Peterson Regional Medical Center Kerrville TX Worse Worse
Plaza Medical Center of Fort Worth Fort Worth TX -- Better
Quail Creek Surgical Hospital Amarillo TX -- Better
Seton Medical Center Austin Austin TX -- Better
Shannon Medical Center San Angelo TX Worse Worse
St Joseph Regional Health Center Bryan TX Worse --
Texas Health Presbyterian Hospital Dallas Dallas TX -- Better
VHS Harlingen Hospital Company LLC Harlingen TX Better Better
Woodland Heights Medical Center Lufkin TX Worse --
Mountain View Hospital Payson UT -- Worse
Carillion Roanoke Memorial Hospital Roanoke VA -- Better
Inova Mount Vernon Hospital Alexandria VA Better --
Reston Hospital Center Reston VA Worse Worse
Sentara Leigh Hospital Norfolk VA Better Better
Southside Regional Medical Center Petersburg VA Worse Worse
Wythe County Community Hospital Wytheville VA Better --
Valley Medical Center Renton WA -- Better
Froedtert Memorial Lutheran Hospital Milwaukee WI Worse Worse
Mercy Health System Corp Janesville WI -- Worse
Orthopaedic Hospital of Wisconsin Glendale WI Better --
St Elizabeth Hospital Appleton WI -- Worse
St Mary’s Hospital Madison WI -- Worse

A dash (--) indicates the hospital had average performance for that indicator.

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