The annual report by Healthgrades listing the top 50 hospitals based solely on clinical outcomes has been released, and 22 states don’t have a single hospital which made the cut.

Nearly 4,500 acute care hospitals, with performance judged on 32 common conditions and procedures, along with “an evaluation of comparative outcomes in appendectomy and bariatric surgery using all-payer data provided by 18 states.” California had the most hospitals of any state, with eight hospitals making the top 50, followed by Michigan and Illinois.

Similar to past reports, Healthgrades emphasized the differences in outcomes at five-star ranked hospitals, saying patients had a 71 percent lower risk of dying and 65 percent lower risk of complications if treated at the highest-ranked hospitals than a facility rated one star in the same category.

“The Healthgrades analysis unequivocally shows that consumers need to educate themselves before any surgery and get the facts on their personal risk in order to improve the likelihood of a positive outcome," said Healthgrades’ chief strategy officer Evan Marks.

If all hospitals had performed up to the five-star standards between 2013 and 2015, the report said on average, more than 223,000 lives could have been saved.

The risk differed among common surgeries. For example, the report said patients having coronary artery bypass grafting (CABG) at a five-star hospital had a 86 percent lower risk of complications or dying over one-star hospital patients.

Along with the report, Healthgrades released a new risk assessment tool for patients called Risk IQ, which judges a patient’s personal risk for complications or death for six procedures: CABG, total knee replacement, hip replacement, bariatric surgery, hysterectomy and pacemaker procedures.