Friday, December 04, 2009

More on the effects of public reporting (and P4P)

This paper, from the Cleveland Clinic Perioperative Medicine Summit, addresses hospital medicine issues that go beyond perioperative medicine.

The discussion kicks off with the story of the cardiac surgery program at the UMass Memorial Medical Center as an example of the effects of public reporting on quality and outcomes. (The episode is recounted in more detail here). After learning of an unexpectedly high mortality, later reported in the Boston Globe, the program was voluntarily suspended. Swift and radical process improvements were made and the program resumed, with improved process metrics and a substantial decrease in mortality. At first glance this could be interpreted as evidence that public reporting improves quality of care which translates into better patient outcomes.

But this episode was an outlier in the world of public reporting. Most public reporting is provided by web sites which the general public pays little attention to. The reports generally provide data on weak performance indicators. The UMass case was different in that mortality rates were reported in the popular media. Also, if I have reconstructed the time line properly, the vigorous process improvement efforts were initiated before the statistics were reported publicly. Questions remain concerning the impact of a lower risk case mix on the reduced mortality after the process improvements. Finally, to what extent did creative clinical documentation influence the severity adjustment applied to the mortality data?

What is the overall effect of public reporting? According to the paper, many studies show that it influences hospitals to make process changes although data on outcomes are inconclusive:

In contrast, the data on whether public reporting improves patient outcomes have so far been mixed. A 2008 systematic review of the literature identified 11 studies that addressed this issue: five studies found that public reporting had a positive effect on patient outcomes, while six studies demonstrated a negative effect or no effect.8 Unfortunately, the methodological quality of most studies was poor: most were before-and-after comparisons without controls.

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