National ranking systems such as the USNWR bolster hospital reputations by emphasizing safety and quality commitment, thereby establishing hospital brands.12,13,14 These rankings evaluate various metrics, including structure, processes, outcomes, safety, and reputation, aiding comparisons across specialties. Such rankings drive positive brand recognition, higher referrals, patient volumes, and quality of care for top-ranked hospitals.44 Nonetheless, care at these top-ranked hospitals may also be associated with higher financial expenditures, and their performance and value of care relative to clinical outcomes, especially for patients undergoing complex procedures, is a matter of ongoing debate among providers and payers.45,46 Therefore, the current study was important as we characterized variations in clinical outcomes and financial costs among patients undergoing surgery for colon cancer at USNWR ranked versus unranked hospitals. Using matched pairs from a nationally representative dataset, the current work demonstrated that top-ranked hospitals had better overall clinical outcomes compared with unranked hospitals. In addition, there was an increasing benefit of treatment at ranked hospitals among patients with poorer health or higher risk of mortality on admission. However, surgical care at ranked hospitals was associated with a greater financial burden that increased with baseline patient risk. Of note, the value of care or ICER for surgical care demonstrated a positive association with increasing patient risk, indicating a trend in which care became more cost effective at ranked hospitals as patient risk worsened.

Variations in clinical outcomes across specialties are closely tied to the hospital in which care is received. Therefore, the choice of hospital for surgery, particularly for cancer surgery, is a crucial decision that can influence patient outcomes, surgical safety, and the overall success of the treatment.47,48 Efforts to improve outcomes have largely focused on improving hospital quality, e.g. through programs such as the Surgical Care Improvement Project by CMS that promotes adherence to evidence-based perioperative care practices through pay-for-performance initiatives.49 However, patient-centric metrics such as the USNWR hospital rankings enable individuals to compare hospitals conveniently based on diverse outcomes across numerous specialties.14 Annually, USNWR evaluates around 5000 medical centers spanning 25 specialties, including cancer, gastrointestinal surgery, cardiology, and orthopedics. Within each specialty, the top 50 hospitals are ranked, with the top 20 earning prestigious honor-roll status, indicating exceptional surgical care quality.50 Despite this perceived influence, there is limited information on quality differences between ranked and unranked hospitals among patients undergoing cancer surgery. Nevertheless, hospital reputation shapes patient decision making regarding choice of hospital for clinical care as rankings influence human psychology, leading patients to associate top USNWR rankings with superior care due to attentional biases and the prestige of high-ranked hospitals evoking positive emotions, which drive decisions based on psychosocial factors rather than specific health needs.51,52 In fact, a survey conducted by Ellis et al. revealed that 61.9% of participants considered hospital rankings as the most critical factor in selecting a hospital.53 The current work examined the relationship between USNWR rankings and clinical outcomes among a 1:1 balanced cohort of patients on a national scale and demonstrated that receiving surgical care at top-ranked hospitals was associated with improved short-term mortality and morbidity, particularly for the highest-risk patients. These findings are in line with a previous study by Wang et al. that demonstrated improved cardiovascular outcomes among patients undergoing treatment at top-ranked hospitals.54 The influence of USNWR rankings on hospital selection most likely impacts choice related to elective surgical cases, as patients requiring urgent care often do not have the opportunity to consider these rankings in their decision-making process.

An improvement in clinical outcomes at ranked hospitals is likely a surrogate for higher annual case volume.55 Ranked hospitals are often research-focused academic tertiary care centers with larger patient volumes, integrating the expertise of various medical professionals, including surgeons, anesthesiologists, radiologists, operating room staff, intensivists, and nurses, to offer multidisciplinary, patient-centered care.56,57,58 The current study also demonstrated that ranked hospitals were more likely to have COTH membership (90.3% vs. 16.1%; p < 0.001), as well as a markedly higher mean number of cases (273 vs. 47.8; p < 0.001) and median number of beds (889 vs. 307; p < 0.001). Nonetheless, there was an increase in mean adjusted cost of care among patients receiving care at ranked versus unranked hospitals. The rate of ICU utilization among ranked versus unranked hospitals was largely comparable. The relatively high ICU utilization rate observed in both ranked and unranked hospital groups may have been attributed to the matched case-control design, in which the selection of controls was dependent on matching with cases. In addition, ICU care may have included patients receiving progressive care unit (PCU)/stepdown care, which may have elevated the reported use of these higher-level care units. Of note, ranked hospitals had much lower failure-to-rescue rates, especially for the highest-risk patients (9.54% vs. 14.47%, difference −4.93%; p = 0.008). In turn, ‘rescuing’ patients from perioperative complications is costly and resource intensive.59 Therefore, mean adjusted surgical costs at ranked hospitals may have been driven, in part, by greater case complexity, higher resource allocation, advanced medical facilities, and elevated staffing levels.60 Additionally, longer hospital stays required to manage complex cases may also contribute to higher cost of care. Although our findings indicate comparable lengths of stay across most patient risk groups, the direct contribution of increased length of stay to overall costs merits further investigation. Specifically, further studies should seek to define how extended care at ranked hospitals influences the cost-effectiveness ratio, thereby affecting the overall value proposition versus unranked hospitals.

Surgery represents a significant expenditure for Medicare services, as surgical episodes of care can be expensive, particularly in relation to in-hospital procedures. On 1:1 matching analysis, the ICER for surgery at ranked versus unranked hospitals decreased approximately threefold, from $9009 to $3387, for a 1% reduction in 30-day mortality among patients with the highest baseline risk on admission. These findings suggested that ranked hospitals may offer a more efficient and cost-effective alternative to unranked hospitals in rescuing patients from major complications. These data may assist policymakers and healthcare providers in optimizing patient care and resource allocation, particularly amid resource constraints and increasing demand for healthcare services. Improving patient outcomes, particularly for high-risk individuals, may be feasible in unranked hospitals despite challenges in implementing gross structural changes by strengthening multidisciplinary care models.61 Collaborative partnerships with higher-ranked institutions can enhance the sharing of clinical knowledge and resources, ultimately raising the standard of care in unranked hospitals.62 Policy interventions are essential to address outcome disparities between ranked and unranked hospitals, especially for high-risk patients. These interventions encompass empowering patient choice and transparency through information about hospital rankings and quality metrics, transitioning to payment models that incentivize value-based care, addressing healthcare disparities by investing in underserved communities, encouraging referrals of high-risk patients to specialized care facilities, and ensuring equitable access to high-quality care for marginalized communities.63,64,65 In tandem with these efforts, addressing the Matthew Effect—an economic principle in which resources tend to be disproportionately allocated to those hospitals already well-resourced, further widening healthcare inequities—is crucial.66 This phenomenon contributes to disparities in healthcare access, as top-ranked hospitals continue to attract more investments and recognition, leaving underresourced institutions, often serving the most disadvantaged populations, with fewer opportunities to improve and provide high-quality care.67 Through these targeted interventions and strategic healthcare planning, all patients need to be provided with access to the best possible care, advancing toward a more equitable and effective healthcare system.

The current study should be interpreted in light of several limitations. As with any retrospective study, selection bias was possible. Use of a large administrative dataset has inherent limitations given the reliance on diagnosis and procedural codes from billing data. Due to the utilization of Medicare claims data, it was likely that racial/ethnic minorities were somewhat underrepresented. The Medicare database included only patients aged 65 years and older, limiting generalizability to other younger and privately insured patient populations. Additionally, data on out-of-pocket (OOP) spending were not assessed, which limited the ability to directly assess patient financial exposure and the element of financial toxicity. Moreover, the Medicare Prospective Payment System (PPS) may influence variations in hospital spending, with PPS-exempt hospitals receiving higher reimbursements due to management of complex cases that require extensive resources.68 Understanding the impact of these exemptions on hospital performance and patient cost burden may be important. The analysis focused on USNWR rankings at a single time point to ensure consistency and facilitate accurate comparisons, avoiding the complexity of fluctuating rankings. Although USNWR accounts for disease severity and complexity in its evaluation of hospitals, due to the nature of the dataset, the current study could not adjust for detailed clinicopathologic factors such as disease stage, histologic characteristics, tumor burden, operative blood loss, and surgical margins. Despite its limitations, Medicare user files represent one of the largest patient population cohorts in the United States.