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In what was called a first-of-its-kind list, the Lown Institute on Tuesday the names of the worst 50 and best 50 hospitals ranked by how frequently their patients had any of 12 procedures largely regarded as unnecessary.

Lown president Vikas Saini, MD, said for the hospitals with the most overuse, "it appears there is a culture. The evidence that these procedures are not useful hasn't penetrated or is being ignored."

For example, Saini said, for someone who is having a heart attack, "a coronary stent is perfectly reasonable. But if someone has very stable angina that they've had for months and months and it's not changing, a coronary stent is unnecessary. Full stop."

At these lower ranked hospitals, the frequent use of unnecessary procedures is often "across the board, with cardiology, radiology, orthopedic surgery procedures," Saini told MedPage Today. "It's not one specialty, and it does suggest there's something going on in the atmosphere, or who the doctors are in a given place."

The institute looked at fee-for-service Medicare claims data during a 3-year period (Jan. 1, 2016 to Dec. 31, 2018) for 3,180 hospitals that performed at least four of 12 low-value procedures.

Hendry Regional in Clewiston, Florida, is at the bottom of the list with the most instances of overuse. For example, of beneficiaries who came to Hendry because they had fainted with no other risk factors, 23% underwent carotid artery imaging and 75% of them got a head CT or MRI.

Nationally, the rate of hospitals that performed carotid imaging for patients with that presentation was 7% and for head imaging, was 23%.

Hendry's marketing director Electa Waddell said the facility is a critical access hospital and shouldn't have been included because only two of the four required types of procedures were performed there. However, a Lown spokesperson checked with the database and said the hospital submitted claims for four types of procedures, and thus qualified.

The second lowest-ranked hospital is Larkin Community Hospital, Palm Springs Campus, in Hialeah, Florida. It reportedly had a carotid screening rate of 29% and a head imaging rate of 65%, and did an electroencephalography (EEG) for syncope (fainting) 17% of the time. Nationwide average of EEG for syncope was 3%, according to a Lown spokesman.

A Larkin representative did not reply to a request for comment.

Besides testing, high rates of hysterectomy and vertebroplasty were generally more common among hospitals on the lower half of the list. At Larkin, 86% of hysterectomies met criteria for overuse. At Martin General Hospital in Williamston, North Carolina, which was fifth from the bottom, 95% of hysterectomies were considered overuse. The national average is 64% for hysterectomy overuse.

Larkin also gave unnecessary vertebroplasty to 14% of patients with spinal fractures; Memorial Hospital Miramar in Florida, which was fourth from the bottom, had a rate of 17%; and CHI St. Luke's Health Memorial in Livingston, Texas (eighth from the bottom) performed the unnecessary procedure in 31% of cases. The national average for vertebroplasty is 6%.

Hospitals that were generally judicious in their use of these low-value procedures (based on a composite score) were also named, with Scott County Hospital in Scott City, Kansas and Beth Israel Deaconess Medical Center in Boston topping the list.

Another general conclusion from the Lown analysis is that New England and Pacific Northwest hospitals seemed to do much better at avoiding low-value procedures. And, only one of the so-called "elite" hospitals, those in highly respected lists such as the U.S. News & World Report honor roll, made the institute's list of the top 100 for avoiding overuse. It was the Cleveland Clinic, which ranked 58th from the top.

Saini warned that overuse isn't just a matter of the hospitals performing more revenue-generating procedures; patients could be harmed.

"When you're getting stuff done that's not necessary, you are subjecting yourself to a risk of harm, and even if the harm is very small, even if the risk is small, it's still real," he said, especially if you're the unfortunate person that develops that complication.

Similar findings were published in an April 27 that was funded by Lown. That paper used a 3-year time period that ended a year earlier and limited its analysis to 2,415 hospitals, which did at least seven of the 12 low-value procedures. The hospitals were not named.

The 12 procedures are as follows:

• Arthroscopic knee surgery in patients with osteoarthritis or "runner's knee"
• Carotid artery imaging for fainting in patients with syncope without history of syncope in 2 years
• Carotid endarterectomy in female patients without stroke symptoms or history of stroke
• Coronary artery stenting in patients with stable heart disease
• EEG for fainting in patients where syncope is the primary diagnosis, and no history of syncope in 2 years
• EEG for headache in patients with headache as the primary diagnosis and no history of headache in the past 2 years
• Head imaging for fainting in patients where syncope is the primary diagnosis, and there is no history of syncope in the past 2 years and excluding patients with epilepsy, convulsions, trauma, altered mental status, nervous and musculoskeletal system symptoms, or history of stroke
• Hysterectomy in patients without a diagnosis of cancer or carcinoma in situ
• Inferior vena cava (IVC) filter in all patients except those with history of multiple pulmonary embolisms
• Renal artery stenting in patients with high blood pressure or plaque buildup in the artery, excluding patients who had a diagnosis of fibromuscular dysplasia of the renal artery (abnormal twisting of the blood vessels)
• Spinal fusion/laminectomy in patients with low-back pain, excluding patients with radicular symptoms, herniated disc, radicular pain, scoliosis; also excluding prior two occurrences within 30 days of radiculopathy, sciatica, or lumbago
• Vertebroplasty in patients with spinal fractures caused by osteoporosis except those with bone cancer, myeloma, or hemangioma

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