Special Report

Cities Where You Don't Want to Get Sick

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Medical errors and suboptimal hospital conditions are a leading cause of death in the United States, resulting in hundreds of thousands of fatalities each year. Of course, some hospitals are worse than others, and the quality of care in a hospital depends largely on where the facility is located.

Clear and effective communication from medical practitioners, clean and quiet rooms, timely treatment, and efficient use of medical technology and resources are all aspects of high-quality hospital care. While best practices such as these do not guarantee the best patient outcomes, hospitals that excel in these areas tend to report lower readmission and death rates — two of the most commonly used metrics when measuring hospital quality.

24/7 Wall St. reviewed readmission rates, mortality rates, and hospital grades published by hospital rating organization Leapfrog Group to identify the metropolitan areas with the worst hospitals. The Hot Springs, Arkansas metro area is the worst area in which to visit a hospital. Visalia-Porterville, California rounds out the list of metros with the worst hospitals in 10th place.

Click here to see the cities where you don’t want to get sick.

Click here to read our methodology.

Nationwide, 15.7% of discharged hospital patients return to the hospital within 30 days. Such patients return with infections after surgery, blood clots left untreated, and other unplanned complications. Readmission rates do not vary tremendously across metropolitan areas. In most of these 10 cities, however, readmission rates are inline with or higher than the national percentage.

Based on a range of expert-determined and government-set standards, including for example the tracking of prescriptions, adequate ICU physician staff, and the patient experience, patient safety watchdog Leapfrog Group rates hospitals A through F. In the most recent assessment, the group found that compared to A-rated hospitals the risk of avoidable death is 35% higher in C hospitals and 50% higher in D and F hospitals. The average grade of hospitals in all of the 10 worst cities is C or worse.

Doctors and nurses are finite resources in hospitals, and inefficiencies in hospital systems can have a considerable impact on patient outcomes. Hospitalizations for illnesses and conditions that should have been treated in outpatient facilities are largely preventable. While the burden presented by preventable hospitalizations can affect the quality of service, the hospitals themselves are not typically to blame. Preventable hospitalizations are common among the uninsured and individuals who receive poor or no primary care — problems that disproportionately affect low income communities in the United States.

Hospital rating methods control for individual risk factors such as age, past medical history, and other conditions that increase the chances of dying or of readmission. Controlling for such parameters aims to evaluate hospitals on the basis of the care they give — regardless of how sick patients are. Once these parameters are controlled for, it appears that external socioeconomic factors — such as high poverty in an area — are the ones that largely explain hospital quality and therefore patient outcomes.

In the report, Quality Reporting That Addresses Disparities in Health Care, published by the American Medical Association in 2014, Harvard physician and researcher Ashish Jha argued that hospital quality scores tend to penalize safety-net facilities, which primarily provide care for disadvantaged and poor populations. Low income populations tend to require greater medical attention, which could skew patient outcome data, even for hospitals providing high quality care.

It is likely no coincidence that all of the worst metropolitan areas in which to get sick are also among the nation’s poorer areas. The median household incomes in all of these areas do not exceed the national median of $53,657 a year. Of the 10 cities, only the Altoona, Pennsylvania area has a poverty rate lower than the national poverty rate of 15.6%.

Correction: A previous version of this article incorrectly characterized some aspects of LeapFrog’s methodology. We wrote for example that the quality of treatment at hospitals was a feature of the hospital score. In fact, while the 30 measures comprising LeapFrog’s hospital scores can be used to evaluate patient safety, the group does not rate hospitals on the quality of treatment of injuries. These errors have been corrected.  

10. Visalia-Porterville, CA
> Readmission rate: 15.6%
> Avg. 30 day mortality rate: 15.1%
> Hospital safety score grade: C
> Preventable hospitalizations: 51.9 per 1,000 patients

Based on the three major hospitals that serve the Visalia metro area the region ranks as the 10th worst in the nation in quality of care. However, as is generally the case, the quality of each facility varies considerably. While Kaweah Delta Medical Center in Visalia received an A from Leapfrog, Tulare Regional Medical Center in Tulare received an F. Unlike other metros with relatively low-rated hospitals, mortality rates among area patients admitted for heart attacks and coronary artery bypass surgery are well below the nationwide average rates — at 12.9% and 2.4%, respectively. For stroke and pneumonia patients, on the other hand, the likelihood of dying after hospitalization is considerably greater than it is in most metro areas.

Socioeconomic conditions likely contribute to the area’s poor hospital ratings. At 28.6%, the Visalia area’s poverty rate is the fifth highest rate of all U.S. metro areas. Individuals living in poverty are at greater risk of certain health conditions.

9. Yakima, WA
> Readmission rate: 15.4%
> Avg. 30 day mortality rate: 14.8%
> Hospital safety score grade: C
> Preventable hospitalizations: 47.6 per 1,000 patients

High rates of preventable hospitalizations, which are usually more common in areas with low health insurance coverage and poor preventative care, strain hospital resources. Despite the relatively high uninsured rate in Yakima, at 16%, the area’s preventable hospitalizations rate of 47.6 per 1,000 patients is below the national figure. Mortality rates, however, for patients admitted to area hospitals for heart conditions and procedures such as stroke and coronary artery bypass surgery are well above the corresponding nationwide rates. The 18.2% of pneumonia patients and 10.1% of whooping cough patients who die within 30 days after hospitalization are also well above the corresponding national rates.

Like a number of other cities on this list, Yakima residents are some of the poorest in the nation. The metro’s poverty rate of 20.3% is considerably higher than the national rate of 15.6%.

8. Albany, GA
> Readmission rate: 16.4%
> Avg. 30 day mortality rate: 14.8%
> Hospital safety score grade: C
> Preventable hospitalizations: 61.4 per 1,000 patients

Of the two hospitals in the Albany area, Leapfrog graded only the two Phoebe Putney Memorial Hospital. The hospital system received a C in the most recent assessment. The relatively poor grade accompanies relatively high readmission and mortality rates across the area’s hospitals, making Albany among the worst cities in which to visit a hospital.

For every 1,000 hospitalizations in the area, 61.4 are unnecessary, well above the national average rate of 54.0 preventable hospitalizations per 1,000 patients. The high rate is likely due in part to poor primary care as well as low health insurance coverage. Nearly 18% of Albany area residents do not have health insurance, considerably higher than the national rate of 11.7%.

7. Altoona, PA
> Readmission rate: 15.3%
> Avg. 30 day mortality rate: 15.1%
> Hospital safety score grade: C
> Preventable hospitalizations: 57.7 per 1,000 patients

Based on a range of measures of practices and outcomes, Altoona metro area hospitals are the worst in Pennsylvania and among the worst in the country. Of those admitted to area hospitals, 15.1% die within 30 days, a higher mortality rate than in all but 16 other U.S. metros. The area’s high mortality rate is largely driven by an especially high pneumonia mortality rate. Nearly one in five patients admitted for pneumonia in Altoona die within 30 days, far more than is typical across the country.

The poor outcomes may be due to outdated prescription practices, and poor communication about medicines, which can lead to medical errors. The UPMC Altoona hospital received below average marks for each of these practices. The hospital also reported an above average incidence of avoidable infections.

6. Elmira, NY
> Readmission rate: 16.4%
> Avg. 30 day mortality rate: 12.7%
> Hospital safety score grade: D
> Preventable hospitalizations: 90.6 per 1,000 patients

Mortality rates from heart and lung-related diseases are generally high in the 10 worst cities in which to get sick. Yet, the 13.9% death rate among patients admitted for pneumonia at hospitals in the Elmira area is among the lowest in the nation. Still, the mortality rates in Elmira for other respiratory conditions such as whooping cough and for heart-related ailments such as stroke are all above average. Also, for every 1,000 hospitalizations in the area, 91 could have been prevented, nearly the highest preventable hospitalization rate of all U.S. metros.

As is often the case in areas with poorly rated hospitals, Elmira residents are not especially wealthy. The city’s poverty rate of 18.7% is well above the national rate of 15.5% and one of the highest in New York. People living in poverty are at greater risk of adverse health outcomes.

5. Yuba City, CA
> Readmission rate: 15.5%
> Avg. 30 day mortality rate: 14.2%
> Hospital safety score grade: D
> Preventable hospitalizations: 53.3 per 1,000 patients

In addition to factors such as age, past medical history, and other conditions that increase the chances of dying, the quality of care at a hospital can also be a major factor affecting an area’s mortality rate. Even when adjusting for these risk factors, Yuba City metro area hospital patients have a higher likelihood of dying from heart-related ailments and procedures such as stroke, coronary artery bypass surgery, and heart failure, as well as from whooping cough and pneumonia, than Americans nationwide.

Unlike most cities on this list, the level of preventable hospitalizations in Yuba City of 53.3 per 1,000 patients is lower than the national rate. However, the Leapfrog Group still rated gave hospitals a D, nearly the lowest grade possible. The Fremont Medical Center received the worst score in the country for its Intensive Care Unit.

4. Clarksville, TN-KY
> Readmission rate: 15.9%
> Avg. 30 day mortality rate: 15.3%
> Hospital safety score grade: C
> Preventable hospitalizations: 76.6 per 1,000 patients

The 15.3% share of people who die within 30 days of being admitted to a hospital in Clarksville is nearly the highest in the country. The high mortality rate is partly the result of the high death rate among patients admitted for pneumonia. More than one in five patients admitted for pneumonia at area hospitals die within 30 days, a higher rate than in all but six other U.S. metros.

The poor outcomes may be due to inefficient allocation of hospital resources. Preventable hospitalizations are an indication of inefficiency, and Clarksville has one of the highest preventable hospitalization rates in the country. For every 1,000 hospital patients, 76.6 could have been treated in an outpatient facility.

3. El Centro, CA
> Readmission rate: 16.4%
> Avg. 30 day mortality rate: 13.8%
> Hospital safety score grade: D
> Preventable hospitalizations: 48.1 per 1,000 patients

Hospital ratings are often accused of unfairly penalizing areas that serve poor residents, who before even visiting a hospital are generally at greater risk of adverse health outcomes. The worst rated metropolitan hospital systems tend to serve relatively poor populations. With a poverty rate of 23.7%, 19th highest of all U.S. metro areas, El Centro is one such example.

Leapfrog rated El Centro’s hospitals very poorly, and other traditional measures of quality of area hospitals, such as the readmission rate, are also relatively poor. On the other hand, 12.2% of patients admitted to hospitals in the area for stroke die within 30 days, one of the lowest mortality rates for stroke patients nationwide.

2. Binghamton, NY
> Readmission rate: 15.5%
> Avg. 30 day mortality rate: 15.2%
> Hospital safety score grade: C
> Preventable hospitalizations: 60.4 per 1,000 patients

The Binghamton metro area is nearly the worst city in which to visit a hospital. Our Lady of Lourdes Memorial Hospital and the United Health Services Hospital network serve the Binghamton metro area. The two hospitals report some of the nation’s highest preventable hospitalization rates, as well as among the highest mortality rates for common fatal ailments. For example, of patients admitted for coronary artery bypass surgery — one of the most commonly performed major operations — 6.4% die within 30 days, the highest such mortality rate of any metro area. After evaluating patient safety at Our Lady of Lourdes, the Leapfrog Group gave the hospital a D.

1. Hot Springs, AR
> Readmission rate: 16.2%
> Avg. 30 day mortality rate: 15.6%
> Hospital safety score grade: C
> Preventable hospitalizations: 68.0 per 1,000 patients

Two hospitals in the Hot Springs metro area, National Park Medical Center and St. Joseph’s Mercy Health Center, received C grades in overall patient safety from Leapfrog. Among a range of other problems, both hospitals ranked below average in preventing infections. Preventable infections, which can occur after surgery, are one major cause of unplanned readmissions to hospitals. The readmission rate of 16.2% in Hot Springs area hospitals is among the higher rates among U.S. metro areas.

The mortality rate in area care facilities is also far higher than is typical across the country, particularly among patients with heart problems. Of those patients admitted for heart failure, 16% die within 30 days of admission, the second highest heart failure mortality rate of any metro area in the country.

Methodology:
To determine the cities with the worst hospitals, 24/7 Wall St. created an index using data from the Centers for Medicare and Medicaid Services (CMS) and other sources. The CMS produces statistics on numerous health measures for most hospitals in the country. We grouped hospitals by their respective metropolitan areas and aggregated each measure to the city level.
Each datapoint was converted into an index using the min-max normalization method. The composite index was calculated from each individual index. A hospital’s mortality rate was given 40% weight. The Leapfrog Group’s safety score made up 30% of the index, readmission rates comprised 20%, and the rate of preventable hospitalizations was given a 15% weight.

First, we calculated a weighted average of 30-day mortality rates for heart attacks, chronic obstructive pulmonary disease (COPD), coronary artery bypass grafting (CABG), heart failure, pneumonia, and stroke to find the average percentage of people who died within 30 days of being admitted to a hospital. For many experts, 30 days is an appropriate window in which a hospital, rather than individual behavior, is at fault for a patient’s death. All mortality rates are risk adjusted.

Second, we included the rate at which individuals were readmitted to a hospital within 30 days of being discharged. Like mortality rates, readmission within 30 days speaks to a health system’s low quality of care and poor communication between hospitals and ambulatory care facilities rather than individual behavior.

We also included the Leapfrog Group’s hospital grading, which considers a host of objective measures related to a hospital’s care delivery as well as responses of patient surveys. Grades range from A to F. To quantify each measure, we assigned A grades a score of 90, B grades a score of 80, and so on. We only included hospitals that existed in both the CMS data and the Leapfrog Group’s data.

Lastly, we used the share of hospitalizations for conditions that could have been treated at outpatient or ambulatory care facilities — often referred to as the unnecessary hospitalization rate. Included in this measure is hospitalization for conditions such as asthma, dehydration, or hypertension. This data came from County Health Rankings.

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