Incorporating natural variation into IVF clinic league tables: The Expected Rank

BMC Med Res Methodol. 2009 Jul 16:9:53. doi: 10.1186/1471-2288-9-53.


Background: Rankings based on outcome are often used to present health care provider performance. These rankings do however not reflect that part of the variation in outcome between providers is caused by natural variation, and not by any differences in quality of care. The aim of this study is to compare standard methods for ranking with a novel method that takes into account natural variation.

Methods: We used data on the number of treatment cycles and the number of pregnancies of 13 Dutch IVF clinics from 2004. We calculated the Expected Rank (ER), an estimate of the true rank of a provider, accounting for natural variation. We rescaled the ER to obtain the Percentile based on ER (PCER), that can be interpreted as the probability that a clinic is worse than a randomly selected other clinic. We also calculated a measure for rankability rho, which is the part of variation between providers that is due to true differences (as opposed to natural variation).

Results: The expected ranks ranged from 1.4 to 11.9 instead of the original ranks 1-13. The ER showed that some clinics performed very similar, which would be disregarded when using standard ranks. The PCER ranged from 7% to 88%. Rankability was substantial (rho = 0.9)

Conclusion: The Expected Rank provides a way to combine the attractiveness of a ranking, a single number and easy interpretation, with reliable analyses that does justice to the providers, and also allows individual comparisons.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Ambulatory Care Facilities
  • Benchmarking
  • Efficiency, Organizational*
  • Health Personnel*
  • Hospitals, Veterans
  • Humans
  • Medical Audit
  • Models, Statistical
  • Outcome Assessment, Health Care
  • Quality Assurance, Health Care
  • Research Design
  • Surveys and Questionnaires
  • United States
  • United States Department of Veterans Affairs