Does Nephrology Need U.S. News & World Report Rankings?

  • 1 T. Alp Ikizler, MD, is currently the Director of the Division of Nephrology and Hypertension, Professor of Medicine, and Catherine McLaughlin Hakim Chair in Vascular Biology at Vanderbilt University Medical Center (VUMC), Nashville, TN. Beatrice Concepcion, MD, MHS, is Associate Professor of Medicine and Medical Director of Kidney and Pancreas Transplantation with the Division of Nephrology and Hypertension at VUMC.
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Annually, U.S. News & World Report (USNWR) publishes a ranking of the best hospitals in the United States by adult specialties. According to the USNWR website, the aim of these rankings is to provide a tool for patients with life-threatening or rare conditions that would help them find skilled inpatient care at a hospital that excels in treating complex, high-risk cases (1). Hospitals are ranked from 1 to 50 in each specialty, and any hospital in the top 10% of all rated hospitals (but not ranked in the top 50) is given a “high performing” designation (1).

In addition to ranking hospitals by specialties, USNWR also rates hospitals on their performance of procedures and treatment of specific conditions. Hospitals are rated as high performing, average, or below average for each specific procedure and condition. Based on the cumulative performance in specialty rankings and procedures and conditions, the Best Hospitals Honor Roll recognizes the nation's top 20 hospitals. In 2020-2021, a hospital's overall score partly came from rankings of 12 “data-driven” specialties (including nephrology) comprising components for patient experience (patient surveys, 5%), discharge-to-home metric (7.5%), reputation (27.5%), structure (capturing staffing and patient services, advanced technologies, external designations [e.g., nurse magnet], trauma center, intensivists, and volume, 30%), and 30-day mortality (30%). A document detailing the methodology for ranking hospitals and specialties can be found on the USNWR website (2).

What changed, and what is the relevance to nephrology?

In an unprecedented move, USNWR did not include nephrology among the 15 adult specialties listed in the 2021-2022 rankings. It is common for USNWR to make changes in its evaluation process on a yearly basis, but based on the communication by USNWR prior to its release, this was not an expected change, at least within the nephrology discipline. Instead of ranking nephrology as a specialty, as has been done in the past, a new “kidney failure” condition was included among 17 procedures and conditions that were rated (3). Although the rationale for this change is not explicit, the USNWR website notes that the kidney failure rating covers nearly all of the same hospital admissions as adult nephrology (1). It is important to note that despite rating hospitals in the treatment of conditions such as chronic obstructive pulmonary disease, congestive heart failure, or diabetes, the specialties of pulmonology and lung surgery, cardiology and heart surgery, and diabetes and endocrinology remain on the list of ranked specialties.

The relevance and utility of USNWR ratings and rankings have been long debated and are not the focus of this commentary. Nevertheless, it is important for the nephrology community to understand what these ratings and rankings represent. First and foremost, the clinical relevance of the USNWR kidney failure rating, the only grading for nephrology in 2021-2022, is limited to only a subset of patients with kidney disease, i.e., ones with acute kidney injury (AKI) (3). In other words, the care delivered by institutions for chronic kidney disease (CKD), end stage kidney disease (ESKD), and kidney transplantation is not included in the evaluation process. Although speculative, this change might be an attempt by USNWR to be consistent with its original premise of “a tool for patients with life-threatening or rare conditions that would help them find skilled inpatient care at a hospital that excels in treating complex, high-risk cases.” AKI does indeed represent a high-risk and life-threating condition, but it constitutes only a small fraction of (hospitalized) patients with kidney disease (see below). Second, USNWR is a customer-oriented service allowing the clients (patients in this case) to explore and choose the product (the hospital in this case) to seek the best care. The ratings are based on the relevant information from the procedure and diagnosis codes. Accordingly, the rating system in place is more than adequate to provide an understanding of whether the hospital can manage a patient with AKI. On the other hand, it is of course debatable how much autonomy or opportunity a patient has when choosing a hospital in the setting of AKI because the condition is usually diagnosed after the index hospitalization, and the choice of kidney replacement therapy is usually straightforward once the patient is hospitalized. In rare circumstances, a patient requiring a complex dialysis procedure may be referred to a tertiary hospital due to the lack of services. Even in that case, the patient has minimal to no input because the options are limited to availability.

In terms of rankings, the previous years did include ESKD and CKD codes, reflecting a more thorough catchment of patients with kidney disease for data-driven nephrology rankings. Some of these conditions included glomerular diseases, gout and diabetes-related kidney disease, and kidney transplant status, although nephrology service covers much more than these select diagnoses, especially only when captured during a hospitalization. The rankings were also influenced by recognition of peers, i.e., how many nephrologists considered the hospital as one of the best. Notably, the selection of these peer groups was dependent on many questionable factors, such as being a part of a mailing list or membership to certain online applications. Finally, the hospital's operational resources and size played a significant role in the final rankings. In the end, it was not surprising to see some highly prestigious institutions dominate the top 10 for many years in a row, regardless of many factors that the nephrology community would consider a reflection of high-quality service.

What is the relevance of ASN's announcement in response to USNWR's rankings?

As the leading entity representing physicians and healthcare workers involved in kidney disease, the American Society of Nephrology (ASN) released a statement when the news broke that nephrology was excluded from data-driven rankings by USNWR. In its statement, ASN highlights several important issues: the significantly limited relevance of these ratings in terms of patient population considered (2%), the importance of recognizing kidney disease that affects almost 1 out of 6 individuals in the United States, and an overview of how rankings and ratings are developed and their implications. In this document, targeted toward patients and their caregivers, ASN pledges to make sure credible and comprehensive information from experts is available to the public, to include all people who need care in these rankings, to avoid inappropriate use of rankings and ratings, and to urge legislation to oversee the objectiveness of these measurements. ASN also provides a short but very comprehensible overview of the rankings.”

How does this impact the nephrology discipline, and what should the kidney community do?

The ASN leadership should be commended for responding to this unexpected change by USNWR. The basic knowledge and impetus provided by this document give us a reason to rethink how we can solidify the importance of kidney disease within the nephrology community as a whole and with our patients. In that sense, it may be a blessing in disguise that USNWR excluded nephrology from its rankings since rankings provide not only very limited information but also potentially unreliable information that could lead to misconception by patients and their caregivers. One of the most appealing aspects of nephrology as a discipline is its unparalleled breadth and depth of patient diversity, ranging from diseases that have a primary impact on kidney histology but normal kidney function to ones where there is no residual function, but patients are still able to live close to a normal life for long periods, unlike in any other solid organ failure. For individuals or institutions managing such a complex and multi-faceted patient population, a single ranking system not only would be unfair, but also unnecessary. It is more reasonable to set quality standards for the best care for our patients with the overall goal of providing optimal kidney disease management. In doing so, it is important to connect the quality goals to the continuum of kidney disease to avoid creating silos of clinical care. Nephrology has always been at the forefront of major advancements in healthcare that have significant, direct implications for patients, such as long-term dialytic therapies, solid organ transplantation, and bundled payment models. It is again nephrologists' responsibility to act, so as to not only participate in currently established quality standards by legislators but also to create and redefine standards that are most important to our patients and their caregivers.