LAUSR

U.S. News & World Report (USNWR) originated as a print news magazine and has evolved into a digital publication focused on ranking many entities, including hospitals and medical specialties. Patients rely on these rankings as a perceived key measure of hospital stature and quality. Rankings for medical specialties, including pediatric urology, are based on a weighted composite score incorporating multiple components, including reputation, hospital quality metrics and procedural outcomes. We question the appropriateness of USNWR outcome assessment methodology and whether USNWR rankings are productive for pediatric urology as a specialty. The ability to prevent surgical complications is the most highly weighted factor in determining USNWR specialty ranking for pediatric urology. Although procedures captured vary somewhat by year, hypospadias complication rates have historically been included as a key component of each institution’s “ability to prevent surgical complications” score. Hospitals are instructed to report complications over a defined period using a prespecified CPT code list. Points are then determined based on reported complication rate ranges. For example programs reporting distal hypospadias reoperation rates less than 1% for 2018 to 2019 received the highest USNWR score, while those reporting reoperation rates greater than 5% received the lowest score. In this issue of The Journal (page 616) Pohl et al analyze data from the Pediatric Health Information System (PHIS) administrative database to evaluate potential limitations related to coding and followup time in USNWR hypospadias complication reporting. Current USNWR methodology only requests capture of 4 specific CPT codes for hypospadias complications. However, surgeons may code for repair of hypospadias complications using different codes. Additionally the followup time for USNWR reporting is 2 to 3 years, yet hypospadias complications happen over a much longer period. When Pohl et al applied USNWR criteria to PHIS to ascertain hypospadias complication rates, the calculated median complication rates were relatively aligned with the most recent USNWR point thresholds. When CPT codes and followup time were expanded, complication rates increased. However, complication rates obtained from PHIS were still lower than those reported by highly ranked pediatric urology programs, particularly for proximal hypospadias. The data presented indicate that use of an administrative database, even with expanded criteria, would still not accurately capture hypospadias complication rates for future USNWR ranking assessments. The data also indicate that point thresholds for hypospadias complications are likely too low, assuming that the USNWR metric aims to capture true complication rates. Uniform, prospective data collection with appropriate risk adjustment is the elusive gold standard strategy that would achieve true equity in complication rate comparison. Examining USNWR methodology for ranking pediatric urology programs generates many questions related to complication assessment and program ranking more globally. We pose several of these questions as “food for thought” for leaders in our field to consider as we determine the future role of USNWR rankings for pediatric urology. What is the role of administrative data in devising point thresholds for USNWR surgical complication rates? The recent PHIS analysis indicates that administrative data may be one tool for exposing potential limitations of the current point system. However, administrative data cannot replace retrospective chart review or (ideally) prospective data collection and assessment of hypospadias complication rates. Should there be external validation of self-reported data? Although complication rates are derived from CPT codes and institutions are asked to provide deidentified procedure lists to USNWR, there is no external validation process. There also is no way to validate/standardize voluntary reporting of reoperations at outside institutions, although reporting of all known reoperations is requested by USNWR. What criteria should exist for determining which procedures are included in the USNWR complication rate data? Perhaps hypospadias repair is not the best procedure to use to compare outcomes. In fact,