The Value of Public Reporting and Transparency
A number of recent journal articles on the subject of public reporting on health care quality collectively underscore the value such transparency holds for hospitals and other providers, consumers, and payers.
In an article in the March issue of Health Affairs, Andrew Ryan and colleagues at Weill Cornell Medical College looked at the Centers for Medicare and Medicaid Services' public reporting initiative, Hospital Compare, which began reporting performance on process-of-care measures in 2005 and outcome measures related to heart attack, heart failure, and pneumonia mortality for nearly all U.S. hospitals in 2007. Based on their analysis of the period 2000 to 2008, which showed no reduction in existing mortality trends for heart attack and pneumonia—and only modest reduction in mortality from heart failure—the researchers suggest that public reporting did not have an impact on mortality. This is not the most relevant finding from this research. Clearly, more than just public reporting is required to improve performance, especially for something as complex as 30-day mortality rates.
What is significant for patients and providers is that through a public reporting program such as Hospital Compare, regularly updated data to evaluate the state of quality in U.S. hospitals are easily and consistently available. For example, we know from analyses of process of care measures reported on Hospital Compare that there have been significant improvements between 2005 and 2011. The recent analyses by Ryan and his colleagues are important because they indicate that mortality rates for three of the most common conditions for which people over 65 are admitted to the hospital have not improved significantly during this time period, suggesting that our efforts to improve this outcome have been insufficient. This finding should spur providers to examine the programs they have in place to reduce mortality. Consumers can likewise use the data to engage in honest conversations with their providers about quality and what they can do to ensure the best outcomes possible.
Improving performance involves a number of steps (plan-do-study-act), and access to data with which to monitor progress is one of them. In order to achieve high levels of quality, data have to be understood and interpreted correctly. Then providers need to take evidence-based action that must be executed properly. So there are several points in the improvement chain where things can go wrong and end up not influencing outcomes at all, or have less of an impact than anticipated.
A Commonwealth Fund-supported article in the same issue of Health Affairs by Geoffrey C. Lamb and colleagues explores one of the critical steps in the chain leading to improved outcomes. The investigators surveyed primary care physicians in Wisconsin to identify how they used data publicly reported via the Wisconsin Collaborative for Health Care Quality. Since 2004, the collaborative has been reporting performance on diabetic processes and outcomes for physician groups comprising about half of Wisconsin primary care physicians. The authors found that, in response to the reported measures, clinics implemented a number of strategies aimed at improving diabetic care and outcomes, including patient, provider, and system-level interventions such as patient education and diabetic registries. Those clinics that had strategic priorities aimed at improving diabetic care that aligned with the publicly reported measures were found to have implemented a higher number of interventions. So, in this case, there is evidence that data transparency led to action on the part of physicians. And trends reported on the Wisconsin public reporting site suggest that outcomes for these measures are improving.
In last week’s Journal of the American Medical Association’s "Clinical Crossroads," Bruce Landon, M.D., M.P.H., M.Sc., argues that quality measures are an essential tool for physicians in effectively managing their patient population, and will help them benefit from new payment models and financial rewards based on performance. Yet in a national survey of physicians, my colleagues and I found that only 33 percent of physicians said they had access to data about the quality of the care they provided. Recent data suggest little change. Public reporting should make it much easier and more convenient for physicians to improve their own practices. Physicians can find out how well they manage certain groups of patients, such as those with diabetes or hypertension, for example, and use data to efficiently implement programs such as group patient visits. Metrics that incorporate patient viewpoints can also keep physicians informed about their patients’ perspectives about their practices, and help physicians engage their patients as partners.
Of course, we have to keep striving for standardization, scientific rigor, and continuous improvement in the measures that are reported, so that they depict meaningful domains of quality and guide action that leads to improved care and outcomes. Yet, the value of a consistent public reporting program such as Hospital Compare, the Wisconsin Collaborative for Health Care Quality or The Commonwealth’s Fund benchmarking tool WhyNotTheBest.org, is clear. These data allow us to assess the state of quality over time, and to prioritize strategies and resources appropriately to reach set goals. Without this information, we’re flying blind.