German hospital rankings questioned

BMJ 2007; 335 doi: (Published 26 July 2007) Cite this as: BMJ 2007;335:177
  1. Annette Tuffs
  1. Heidelberg

    The first nationwide hospital ranking in Germany has provoked controversial discussions about the importance and reliability of league tables in health care.

    The statutory health insurance company Techniker Krankenkasse, with 6.1 million members, has published the results of a telephone survey of more than 100 000 patients on their recent stay in a hospital.

    The patients were asked how satisfied they were with the results of treatment, the medical and nursing care, and the accommodation provided by the hospital. The survey was also covered in Germany's main tabloid newspaper, Bild, as a list of Germany's 200 best hospitals.

    On the basis of the results of the survey and the official hospital quality reports from 2005, Techniker Krankenkasse has set up a search for the best hospital for most diseases on its homepage,

    “Most patients do not want to rely on the recommendations of doctors any more when they choose a hospital, they want to profit from the experiences of other patients and search the internet,” said Christoph Straub, member of the board of directors of the company, speaking at the presentation of the survey in Berlin in June.

    Critics found severe flaws with the hospital ranking, however. Not all hospitals in Germany were included because they did not all fulfil the condition that at least 300 interviewees had to have stayed in the hospital.

    Additionally, said Stefan Etgeton from the National Association of Consumer Advice Centres, health insurance companies could not be independent advisers on the quality of hospitals because they tend to have contracts with individual hospitals or chains of hospitals. The German Hospital Society asked whether patients' satisfaction was a truly reliable criterion for quality of health care. “Patients also care for soft factors, like the way doctors talk to them,” said Mr Straub.

    Hospital rankings are a novelty in Germany. So far only Berlin, Hamburg, and the Rhine-Ruhr area around Essen have published hospital guides, based on regional surveys. But in November 2007, when all hospitals have to publish their second obligatory quality reports, a flood of hospital rankings and search facilities on the internet for best hospital treatment are expected.

    Already the national quality institute, Bundesgeschäftsstelle Qualitätssicherung, has published data on the internet on outcomes of treatments—for instance, for artificial hip and knee replacement, breast cancer, and gallbladder surgery—from 1500 German hospitals. The hospitals are obliged to report their outcome data to the institute. Previously, however, data were not published, and in recent online publication the names of hospitals were left out.

    The data show that hospitals that treat no more than 20 cases per disease a year have worse results and therefore higher risks. For instance, of 206 small hospitals, some have a risk of infection of as much as 100% after hip replacement. Furthermore, unnecessary and non-standard treatments were more common in small hospitals.

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