What It Takes to Be a Top 10 Stroke Hospital

Andrew N. Wilner, MD


December 17, 2018

Medscape recently published its annual physician survey of the top hospitals in the United States. More than 11,000 physicians responded with their top hospital choices for conditions including amyotrophic lateral sclerosis, cardiac conditions, cardiac surgery, hepatitis C, hip replacement, infectious diseases, multiple sclerosis, pediatric conditions, spinal cord injury, and stroke.

Physicians based their ratings on these criteria:

  • Medically respected expertise (45%)

  • Reputation (17%)

  • Specific physician (12%)

  • Technology (10%)

  • Low error rates (6%)

  • Publications (4%)

  • Low infection rates (3%)

  • Participation in clinical trials (2%)

  • Readmission rates (1%)

  • Other (1%)

Admittedly, this survey contains subjective elements, and one could quibble with the ranking. But with such a large number of physician respondents, the results are worth noting.

US News & World Report Survey

US News & World Report also publishes a "Best Hospitals Honor Roll."[1] Its ranking criteria are:

  • Survival (37.5%)

  • Nurse staffing, patient volume, technologies and other measures (30%)

  • Expert opinions from board-certified physicians (27.5%)

  • Patient safety (5%)

While "survival" is undoubtedly an important measure, it's a low bar for excellence. Survival as an endpoint also fails to consider illness severity, an important prognostic factor, which may lead to misleading ranking. For example, better hospitals that treat sicker patients may report higher mortality due to their patient population rather than deficient medical or technical expertise. The remaining US News & World Report criteria are similar to those used by Medscape.

Making the Top 10 Stroke Hospitals

As a neurologist at a teaching hospital that didn't make the top 10, I thought a closer look at the qualities shared by the hospitals that did might prove enlightening. Because stroke constitutes a large segment of our inpatient neurology service, that seemed a good place to start. These are the top 10 stroke hospitals:

  1. Mayo Clinic Hospital, Methodist Campus

  2. Massachusetts General Hospital

  3. Cleveland Clinic

  4. The Johns Hopkins Hospital

  5. NewYork-Presbyterian/Columbia University Medical Center

  6. Ronald Reagan UCLA Medical Center

  7. Stanford Hospital

  8. Northwestern Memorial Hospital

  9. Hospital of the University of Pennsylvania

  10. Duke University Hospital

Judging the Criteria That Judges Hospitals

"Medically respected expertise," which constituted 45% of the ranking, probably translates into one or more "big names" in the field. At least one medical expert, and preferably several, constitutes an essential building block for hospital excellence.

For example, a quick PubMed search reveals that Dr Waleed Brinjikji, an interventional radiologist at the No.1 Mayo Clinic, has more than 40 publications...in 2018! That qualifies as a big name and fulfills the third category of "specific physician," as well as the less important category of "publications."

At my hospital, we don't have any big names in stroke, although there is at least one cerebrovascular luminary at the hospital down the road.

The Joint Commission has established four stroke center categories[2]:

  1. Acute stroke-ready hospital

  2. Primary stroke center

  3. Comprehensive stroke center

  4. Thrombectomy-capable stroke center

To qualify as a thrombectomy-capable stroke center, the highest level of stroke tertiary care, many services must be in place including a neurointerventionalist, a neurologist, a neuroradiologist, and a neurosurgeon, available 24/7; dedicated neurointensive care beds for complex-stroke patients, neurointensivist coverage, and the ability of an acute stroke team to arrive at the bedside within 15 minutes. These Joint Commission criteria highlight that the category of medically respected expertise includes dedicated facilities like ICU beds, appropriate numbers of specially trained nurses, and 24/7 readiness.

The second category, "reputation," is more global and nebulous, and follows from the first category. Great doctors gravitate to great centers, and great centers help great doctors flourish. In order to attain and maintain a great reputation, a hospital must run efficiently. No matter how much medical expertise it offers, a hospital will not radiate a glowing reputation if it loses records, misplaces lab samples, mistreats patients, has insufficient parking, and doesn't insist on a well-functioning, patient-friendly facility.

Reputation also depends, to some degree, on public relations efforts that share medical successes and cutting-edge research. The Mayo Clinic Department of Public Affairs shines in this respect. Their job is made easier, as they have much to crow about.

The fourth criterion, "technology," refers back to the first. Big names can't provide state-of-the-art care without reliable and sophisticated equipment, such as linear accelerators and intraoperative MRI.

The fifth measure, "low error rates," goes without saying. Errors are inevitable, but their frequency diminishes when high standards are coupled with extraordinary expertise.

"Publications," in and of themselves, only accounted for 4% of the score. However, this criterion is probably underweighted, as peer-reviewed publications are partly responsible for creating the big names so essential to acquire a national reputation.

A high infection rate undermines surgical results, making "low infection rates" a sine qua non for successful surgical centers.

Surprisingly, "participation in clinical trials" only accounted for 2% of the score. In my experience, physicians and medical centers that carry out clinical trials tend to perform at the cutting edge of their field.

"Readmission rates" and "other" each only constituted 1% of the score.

Excellence Across the Board

Hospitals that excelled in one specialty often displayed excellence across the board. For example, two of the top three hospitals for stroke were also in the top three for hip replacement (the Mayo and Cleveland Clinics), a specialty that relies upon a different set of medical specialists and equipment. Massachusetts General Hospital was No. 2 for stroke, but drifted down to No. 4 for hip replacement. Given the subjective nature of the rankings, this small change is probably not very significant.

This phenomenon that top hospitals possess high ranks in more than one area testifies to a depth of administrative, medical, and technical expertise. Not every hospital that is outstanding for one medical disorder will demonstrate excellence in all the others, but it's unlikely they will be terrible in any.

It's tough to be a top 10 hospital for stroke or any other medical condition. This accomplishment requires not only superb talent, but also an optimally equipped and well-run facility.

Although imperfect, hospital quality surveys highlight examples of success and should help guide administrators and those tasked with improving quality of care. Who knows, with enough effort and resources, maybe someday we'll make the top 10!


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