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Tell Me Something New: Report Cards and the Referring Physician
... The main challenge of the literature is that most studies did not distinguish between consumer's learning from report cards and that from non-report-card mechanisms that would occur independently of report cards [2][3][4]. While many other studies did either control for the effect of private learning or estimate the magnitude of it [5][6][7][8][9][10][11][12], the main issue with this set of studies is that they commonly assume that consumer learning from public report cards is independent of that from private channels, which may be not plausible. ...
... The explanation for this finding is likely multifactorial and may be related to such issues as surgeon availability, patient preference, financial and interpersonal considerations, restrictions related to insurance, ease of coordinating care, clinical stability for transfer, and institutional loyalty. 11,12 The importance attributed to hospital affiliation ( Figure) is consistent with the fact that nonclinical factors, such as market consolidation, may be driving some referrals. Regardless of the reasons, the current practice of cardiologists not referring to surgeons with the lowest mortality likely contributes to the wide range of risk-adjusted mortality rates for CABG among individual surgeons in the most recent New York State report card (from 0% to 13.4%). ...
Background:
Report cards of risk-adjusted mortality rates of individual cardiac surgeons have been publicly available in New York State since 1991. A survey of New York cardiologists in 1996 found that these report cards had little effect on their referral recommendations to cardiac surgeons. It is unknown whether the influence of report cards on referral behavior has changed over time.
Methods and results:
We surveyed cardiologists in New York State in 2011 to determine their awareness of cardiac surgeon report cards, their use of the report card in formulating judgments about the quality of cardiac surgeons and selecting cardiac surgeons for referral of patients, and discussion of the report with patients in need of cardiac surgery. The relation between demographic (age, sex) and professional (teaching, board certification, faculty appointment, general cardiology practice, and hospital employee) characteristics and the influence of report cards on referral decisions was assessed using χ(2) for categorical variables and t test for continuous variables. Multivariable logistic regression models were created to determine the independent association of any variable with P<0.1 on univariate analysis. Almost all (94%) cardiologists were aware of report cards of cardiac surgeons. The influence of the report cards on cardiologists' referral decisions was limited, with 25% of cardiologists reporting a moderate or substantial influence on referral decisions. The report card was not discussed with any patients by 71% of cardiologists. The mean age of cardiologists reporting moderate or substantial influence of report cards was 58 years compared with 54 years for those who reported no/little influence (P=0.012). Fewer cardiologists who reported moderate or substantial influence were board certified (91% versus 99%; P=0.003). On multivariate analysis, general cardiology practice and employment by a hospital were independently associated with greater report card influence (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P=0.13).
Conclusions:
After 20 years of public reporting and almost universal awareness of cardiac surgeon report cards, in 2011, cardiologists in New York State made little use of this information and rarely discussed it with patients at the time of referral for cardiac surgery.
The authors say public reporting of even the most well-defined end points—survival after treatment—can be misleading when used to compare outcomes across providers, and these data can suffer from patient-selection and treatment-intensity biases.
Patients who receive surgery from high-volume surgeons tend to have better outcomes. Black patients, however, are less likely to receive surgery from high-volume surgeons.
Among men with localized prostate cancer, we examined whether disparities in use of high-volume urologists resulted from racial differences in patients being diagnosed by high-volume urologists and/or changing to high-volume urologists for surgery.
Retrospective cohort study from Surveillance, Epidemiology, and End Results-Medicare data.
A total of 26,058 black and white men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with localized prostate cancer from 1995 to 2005 that underwent prostatectomy. Patients were linked to their diagnosing urologist and a treating urologist (who performed the surgery).
Diagnosis and receipt of prostatectomy by a high-volume urologist, and changing between diagnosing and treating urologist
After adjustment for confounders, black men were as likely as white men to be diagnosed by a high-volume urologist; however, they were significantly less likely than white men to be treated by a high-volume urologist [odds ratio 0.76; 95% confidence interval (CI), 0.67-0.87]. For men diagnosed by a low-volume urologist, 46.0% changed urologists for their surgery. Black men were significantly less likely to change to a high-volume urologist (relative risk ratio 0.61; 95% CI, 0.47-0.79). Racial differences appeared to reflect black and white patients being diagnosed by different urologists and having different rates of changing after being diagnosed by the same urologists.
Lower rates of changing to high-volume urologists for surgery among black men contribute to racial disparities in treatment by high-volume surgeons.
The call for accountability in health care quality has fueled the development of consumer-oriented Web sites that provide hospital ratings. Taking the consumer perspective, we compared five Web sites to assess the level of agreement in their rankings of local hospitals for four diagnoses. The sites assessed different measures of structure, process, and outcomes and did not use consistent patient definitions or reporting periods. Consequently, they failed to agree on hospital rankings within any diagnosis, even when using the same metric (such as mortality). In their current state, rating services appear likely to confuse, rather than inform, consumers.
Quality report cards have become common in many health care markets. This study evaluates their effectiveness by examining the impact of the New York State (NYS) Cardiac Surgery Reports on selection of cardiac surgeons. The analyses compares selection of surgeons in 1991 (pre-report publication) and 1992 (post-report publication). We find that the information about a surgeon's quality published in the reports influences selection directly and diminishes the importance of surgeon experience and price as signals for quality. Furthermore, selection of surgeons for black patients is as sensitive to the published information as is the selection for white patients.
Previous reviews have shown inconsistent effects of publicly reported performance data on quality of care, but many new studies have become available in the 7 years since the last systematic review.
To synthesize the evidence for using publicly reported performance data to improve quality.
Web of Science, MEDLINE, EconLit, and Wilson Business Periodicals (1999-2006) and independent review of articles (1986-1999) identified in a previous systematic review. Only sources published in English were included.
Peer-reviewed articles assessing the effects of public release of performance data on selection of providers, quality improvement activity, clinical outcomes (effectiveness, patient safety, and patient-centeredness), and unintended consequences.
Data on study participants, reporting system or level, study design, selection of providers, quality improvement activity, outcomes, and unintended consequences were extracted.
Forty-five articles published since 1986 (27 of which were published since 1999) evaluated the impact of public reporting on quality. Many focus on a select few reporting systems. Synthesis of data from 8 health plan-level studies suggests modest association between public reporting and plan selection. Synthesis of 11 studies, all hospital-level, suggests stimulation of quality improvement activity. Review of 9 hospital-level and 7 individual provider-level studies shows inconsistent association between public reporting and selection of hospitals and individual providers. Synthesis of 11 studies, primarily hospital-level, indicates inconsistent association between public reporting and improved effectiveness. Evidence on the impact of public reporting on patient safety and patient-centeredness is scant.
Heterogeneity made comparisons across studies challenging. Only peer-reviewed, English-language articles were included.
Evidence is scant, particularly about individual providers and practices. Rigorous evaluation of many major public reporting systems is lacking. Evidence suggests that publicly releasing performance data stimulates quality improvement activity at the hospital level. The effect of public reporting on effectiveness, safety, and patient-centeredness remains uncertain.
Context.— Publicly released performance reports ("report cards") are expected
to foster competition on the basis of quality. Proponents frequently cite
the need to inform patient choice of physicians and hospitals as a central
element of this strategy.Objective.— To examine the awareness and use of a statewide consumer guide that
provides risk-adjusted, in-hospital mortality ratings of hospitals that provide
cardiac surgery.Design.— Telephone survey conducted in 1996.Setting.— Pennsylvania, where since 1992, the Pennsylvania Consumer Guide to Coronary Artery Bypass Graft [CABG] Surgery has provided
risk-adjusted mortality ratings of all cardiac surgeons and hospitals in the
state.Participants.— A total of 474 (70%) of 673 eligible patients who had undergone CABG
surgery during the previous year at 1 of 4 hospitals listed in the Consumer Guide as having average mortality rates between 1% and 5%
were successfully contacted.Main Outcome Measures.— Patients' awareness of the Consumer Guide,
their knowledge of its ratings, their degree of interest in the report, and
barriers to its use.Results.— Ninety-three patients (20%) were aware of the Consumer
Guide, but only 56 (12%) knew about it before surgery. Among these
56 patients, 18 reported knowing the hospital rating and 7 reported knowing
the surgeon rating, 11 said hospital and/or surgeon ratings had a moderate
or major impact on their decision making, but only 4 were able to specify
either or both correctly. When the Consumer Guide
was described to all patients, 264 (56%) were "very" or "somewhat" interested
in seeing a copy, and 273 (58%) reported that they probably or definitely
would change surgeons if they learned that their surgeon had a higher than
expected mortality rate in the previous year. A short time window for decision
making and a limited awareness of alternative hospitals within a reasonable
distance of home were identified as important barriers to use.Conclusions.— Only 12% of patients surveyed reported awareness of a prominent report
on cardiac surgery mortality before undergoing cardiac surgery. Fewer than
1% knew the correct rating of their surgeon or hospital and reported that
it had a moderate or major impact on their selection of provider. Efforts
to aid patient decision making with performance reports are unlikely to succeed
without a tailored and intensive program for dissemination and patient education.
Publicly released performance reports ("report cards") are expected to foster competition on the basis of quality. Proponents frequently cite the need to inform patient choice of physicians and hospitals as a central element of this strategy.
To examine the awareness and use of a statewide consumer guide that provides risk-adjusted, in-hospital mortality ratings of hospitals that provide cardiac surgery.
Telephone survey conducted in 1996.
Pennsylvania, where since 1992, the Pennsylvania Consumer Guide to Coronary Artery Bypass Graft [CABG] Surgery has provided risk-adjusted mortality ratings of all cardiac surgeons and hospitals in the state.
A total of 474 (70%) of 673 eligible patients who had undergone CABG surgery during the previous year at 1 of 4 hospitals listed in the Consumer Guide as having average mortality rates between 1% and 5% were successfully contacted.
Patients' awareness of the Consumer Guide, their knowledge of its ratings, their degree of interest in the report, and barriers to its use.
Ninety-three patients (20%) were aware of the Consumer Guide, but only 56 (12%) knew about it before surgery. Among these 56 patients, 18 reported knowing the hospital rating and 7 reported knowing the surgeon rating, 11 said hospital and/or surgeon ratings had a moderate or major impact on their decision making, but only 4 were able to specify either or both correctly. When the Consumer Guide was described to all patients, 264 (56%) were "very" or "somewhat" interested in seeing a copy, and 273 (58%) reported that they probably or definitely would change surgeons if they learned that their surgeon had a higher than expected mortality rate in the previous year. A short time window for decision making and a limited awareness of alternative hospitals within a reasonable distance of home were identified as important barriers to use.
Only 12% of patients surveyed reported awareness of a prominent report on cardiac surgery mortality before undergoing cardiac surgery. Fewer than 1% knew the correct rating of their surgeon or hospital and reported that it had a moderate or major impact on their selection of provider. Efforts to aid patient decision making with performance reports are unlikely to succeed without a tailored and intensive program for dissemination and patient education.
Provider report cards feature prominently in ongoing efforts to improve patient quality. A well-known example is the cardiac surgery report-card program started in New York, which publicly compares hospital and surgeon performance. Public report cards have been associated with decreases in cardiac surgery mortality, but there is substantial disagreement over the source(s) of the improvement. This article develops a conceptual framework to explain how report-card-related responses could result in lower mortality and reviews the evidence. Existing research shows that report cards have not greatly changed referral patterns. How much providers increased their quality of care and altered their selection of patients remains unresolved, and alternative explanations have not been well studied. Future research should expand the number of states and years covered and exploit the variation in institutional features to improve our understanding of the relationship between report cards and outcomes.
Cardiac surgery — most notably, coronary-artery bypass grafting (CABG) — is the longest-standing and most common focus of public report cards. Cardiac surgeons might feel that they are being subjected to a unique level of scrutiny, but Dr. Robert Steinbrook writes that the attention goes with the territory.
New York: Harper Perennial Modern Classics
- R Pirsig
- Zen
Pirsig R. Zen and the Art of Motorcycle Maintenance. New York: Harper Perennial Modern Classics; 2008.