Key Words: report cards, quality assurance, quality indicators, accountability
Report cards have been instituted within the health care delivery system in the past few years to provide consumers with quality measures upon which to base decisions regarding care and to improve quality by encouraging competition among providers. Although critics charge these quality reports may not be having the intended consequences, it is likely that in an age of increasing accountability and of funding tied to outcomes that we will see more such projects launched followed by refinements in their content and presentation.
The Most Recent Report Card: Hospital Compare
The most recent launch of a health report card for hospitals was by the U.S. Centers for Medicare and Medicaid Services (CMS). The CMS public Web site (www.hospitalcompare.hhs.gov) provides consumers with information on how often participating hospitals follow recommended guidelines for patients with three specific conditions: heart attacks, heart failure, and pneumonia.
This report card is a project of CMS and the Hospital Quality Alliance, which is a public-private collaboration of organizations that support the reporting of hospital quality of care. This includes Federal agencies, consumer groups, employers, accrediting organizations, hospitals, and health providers. More than 4,200 acute-care hospitals and critical access hospitals are participating. Hospital participation is voluntary, although all but the smallest hospitals potentially may lose a portion of their Medicare payments if they elect not to participate. The data collected are not restricted to that from elderly and disabled patients, but are from all patients with the selected conditions regardless of age. Hospitals report their data quarterly to a state agency. A random check is done against actual patient files to insure accuracy of the submission.
In this first phase of the report card, hospitals are measured on how often they follow nationally recognized treatment guidelines, as opposed to patient outcomes. For pneumonia care, for example, the report compares the percentage of patients that received an initial antibiotic within 4 hours of arriving at the hospital. Future reports will include the extent of post-surgical infections and patient satisfaction. Medicare payments will increasingly be connected to quality measures such as these. Mark McClellan, administrator of the Centers for Medicare and Medicaid Services has said that "We strongly believe that payment incentives work to get quality reporting and quality improvement, when we use measures that are clinically valid and feasible to produce."
A consumer can search for hospital information by state, county, city, zip code, or by hospital name. Then the consumer chooses the condition and treatment of interest. The system provides a bar chart comparing the selected hospital(s) to the national and regional averages. It is also possible to connect to the data tables which show how many patients were treated by the selected hospital(s). The site also provides general information about the quality care measures: what they are and a brief explanation of them and a statement of why there are sometimes exceptions to recommended care. The site also includes sections on data collection directed both to consumers and professionals, as well as links to other related resources.
Other Report Cards
In January 2003, ConsumerReports.Org did an article on "How safe is your hospital?" (This has a very long Web address. To connect, go to www.consumerreports.org and click on the "Health and Fitness" tab; under "Health Care" click on "more" and then under "Doctors and insurance," you will find Hospitals: how safe?). This article gives excellent advice to consumers about how to maximize the quality of care received when hospitalized.
In the left-hand column of this article, ConsumerReports.Org links to a useful directory of other hospital report cards, advising readers that these do not use a standardize report format, nor do they use they same measures for quality care. The listing includes those with national scope (such as the "America’s Best Hospitals" from U.S. News & World Report and "Quality Check" from the Joint Commission on Accreditation of Healthcare Organizations), as well as a listing of reports by selected states (California, Florida, Illinois, Iowa, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, Virginia, Washington, Wisconsin).
Consumer Reports provides some interpretative advice: if needing surgery and having a choice of hospitals, choose those with higher volume numbers or whose death rates seem lower than others in the region. For the best all-around hospital, compare with others in the region.
Report Card Critiques
At the very time the CMS Hospital Compare site was launched, several articles concerned about the effect of such report cards appeared in the literature. Werner and Asch (2005) highlighted the two sought after benefits of public reporting: allowing health consumers to select high-quality providers and motivating those providers to improve quality to become more competitive. They maintain, however, that:
Public reporting of quality information promotes a spirit of openness that may be valuable for enhancing trust of the health professions, but its ability to improve health remains undemonstrated, and public reporting may inadvertently reduce, rather than improve, quality. Given these limitations, it may be necessary to reassess the role of public quality reporting in quality improvement. (p.1239)
The concern that physicians may be avoiding sick patients in order to preserve or improve their quality ranking was supported by a study Werner, Asch, and Polsky published in Circulation in 2005. They analyzed data reported on coronary artery bypass grafts (CABG) from New York State compared with control states from the Healthcare Cost and Utilization Project (HCUP-3) for the period 1988-1995. Their findings showed that CABG surgery in New York between whites and minorities differed more widely after a report card was released. Following its issuance, blacks and Hispanics were less likely to receive CABG than whites. A comparable difference was not seen in the control states. The authors also noted that the data on minority groups did not show an increase in angioplasty procedures, although that is often a substitute procedure for CABG. They advocated improvements to report cards to aid consumers in being more discriminating and to insure physicians that appropriate risk adjustment measures are in place.
Similarly, a recent study in the Archives of Internal Medicine (Narins, Ling, Zareba, & Dozier, 2005) found 80% of interventional cardiologists in New York have avoided performing a risky, but potentially life-saving, angioplasty on a patient for fear that a death could skew the physician’s mortality report card. Although the scoring system used in New York is designed not to penalize physicians as much when a death occurs in a severely ill patient following a procedure, the physicians reported they did not think the adjustment was sufficient to avoid punishing physicians undertaking the higher-risk interventions.
One of the most compelling overviews of health report cards was issued as a "Research Highlight" by the RAND Corporation in 2002. The report was critical of the fact that only modest evaluation has been done on the effectiveness of the report cards. Their study found that the evaluation that was published showed consumers and physicians make relatively little use of these quality reports. It appears that hospitals do pay attention and respond. The reasons they identified for lack of use by consumers included that the information was: too technical, not relevant to their need, too extensive, lack of time to review, concern about its trustworthiness. The RAND authors suggested usability could improve if: consumers were provided guides for using the report card, educational efforts were made to better inform consumers and professionals about these quality assessments and their use, and more efforts were undertaken to understand utilization of the report cards and how they might be improved.
In a period of increasing commitment to measuring outcomes and insuring quality, we can expect that health report cards are here to stay. Hospitals Compare appears to have addressed some of the concerns raised by the RAND report by providing interpretative comments for consumers and information on how the data were gathered for health professionals. Tying participation in the report card to Medicare reimbursement will insure hospitals and physicians stay engaged with the effort. We can assume we will continue to live and work in a culture of accountability and must do our part to make it positive endeavor.
Barbara F. Schloman, PhD, AHIP
Assistant Dean, Library Information Services
Libraries & Media Services
Kent State University
Kent, OH 44242
Disclaimer: Mention of a Web site does not imply endorsement by the author, OJIN, or NursingWorld. Links to web sites are current at the time of publication, but are not subsequently updated.
Narins, C. R., Dozier, A. M., Ling, F. S., & Zareba, W. (2005). The influence of public reporting of outcome data on medical decision making by physicians. Archives of Internal Medicine, 165, 83-87.
RAND Corporation. (2002). Research highlights: Report cards for health care--Is anyone checking them? Retrieved April 5, 2005 from www.rand.org/publications/RB/RB4544/
U.S. Centers for Medicare and Medicaid Services. (2005, April 1). Press release: Information on hospital quality now available. Retrieved April 5, 2005 from /www.cms.hhs.gov/media/press/release.asp?Counter=1409
Werner, R. M., & Asch, D. A. (2005, March 9). The unintended consequences of publicly reporting quality information. JAMA,293 (10): 1239-1244. Retrieved April 5, 2005 from http://jama.ama-assn.org/cgi/reprint/293/10/1239.pdf
Werner, R. M., Asch, D. A., & Polsky, D. (2005). Racial profiling: The unintended consequences of coronary artery bypass graft report cards. Circulation, 111, 1257-1263.