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Background: U.S. News & World Report's annual rankings of the top 50 American hospitals in 12 specialties are based on a combination of subjective and objective measures of quality. Although the rankings have been criticized for emphasizing the subjective reputation of hospitals too strongly, the role of reputation in determining the relative standings of the top 50 hospitals has not been quantified. Objective: To quantify the role of reputation in determining the relative standings of the top 50 hospitals in the 2009 edition of U.S. News & World Report's rankings. Design: Cross-sectional study. Setting: The top 50 hospitals in each of 12 specialties. Measurements: Rankings based on the total U.S. News score and on a subjective reputation score. Results: On average, rankings based on reputation score alone agreed with U.S. News & World Report's overall rankings 100% of the time for the top hospital in each specialty, 97% for the top 5 hospitals, 91% for the top 10 hospitals, and 89% for the top 20 hospitals. Hospital reputation was minimally associated with objective quality measures (mean Spearman [[rho].sup.2] = 0.03). Limitation: The findings apply primarily to interpretations about the relative standings of the 50 top-ranked hospitals in each specialty and not necessarily to the hundreds of unranked hospitals. Conclusion: The relative standings of the top 50 hospitals largely reflect the subjective reputations of those hospitals. Moreover, little relationship exists between subjective reputation and objective measures of hospital quality among the top 50 hospitals. Primary Funding Source: None.