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What Can We Say about the Impact of Public Reporting? Inconsistent Execution Yields Variable Results

Judith H. Hibbard, DrPH
[+] Article, Author, and Disclosure Information

From University of Oregon, Eugene, OR 97403-1209.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Judith H. Hibbard, DrPH, Department of Planning, Public Policy and Management, University of Oregon, Eugene, OR 97403-1209.

Ann Intern Med. 2008;148(2):160-161. doi:10.7326/0003-4819-148-2-200801150-00011
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Improving the quality of care is a high priority for those who pay for and regulate health care. Yet, policymakers have a limited number of levers for encouraging efforts to improve quality. The most frequently used approach is to measure and report health care performance. The theory is that making information on performance publicly available will motivate practitioners, plans, and hospitals to improve in order to protect or expand their market share. Thus, the policy approach relies largely on consumers' attention to and use of information about quality of care. The underlying assumption is that consumers will want and use information about comparative performance. Experience to date, however, does not support this assumption. Consumers have been slow to take an interest in these comparative reports and to use them in choosing a physician, health plan, or hospital. Considerable resources go into the measurement of performance and public reporting. To what degree is the investment achieving its intended outcomes?

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Constraints on Efficacy of Quality-Reporting
Posted on February 19, 2008
Jeremy D Graham
Community Health Association of Spokane
Conflict of Interest: None Declared

Fung et al have contributed an important analysis to quality improvement methods in biomedicine (1). Except for some efficacy at the hospital level, the effect of publicly-reported quality scores seems to be minimal from the existing data (although that data is scant). Interestingly, Hibbard's editorial urges readers "not to give up on the consumer model," to which she has contributed some of the publications cited in her own discussion (2). Further technical refinement in the reporting itself is urged, assuming that once it is sufficiently developed, the quality-reporting will work properly. This presumes that patients are positioned like the consumers of any other commodity"”and that medical care will behave in a marketplace, as do less socially- complicated goods. Professor Hibbard urges deeper exploration of quality- reporting pathways effects, but fails to address a central lesson of Fung's publication: the conjectured pathways didn't show much existence of effects to explore further. Before devoting further resources to further refine these techniques, we must question whether quality-reporting (as currently conceived) is truly a sufficient tool.

Report-card quality improvement strategies can fail for both clinical and social reasons. Clinical circumstances limit their utility: care of trauma, acutely-ill nursing home dwellers, or patients with acute coronary syndromes transported emergently are just a few examples. Pathways to care which are incommodious to pre-screening by consumers are legion. Secondly, a patient free to make "consumer" decisions rarely exists in praxis. Our primary-care clinicians' own hospital affiliations, the "in- network" constraints of employer-based insurances, and neighborhood locations all limit patients' agency to choose their care. Indeed, one of the studies cited by Fung and associates actually demonstrated a relative gravitation of only more the affluent patients to better-scoring surgeons after scores were published (3); knowledge is power only for those with sufficient social capital.

Perhaps we should not, indeed, fully give up on these public- reporting methods, even given the paucity of efficacy findings (an appreciable at the hospital level is certainly worth cultivating). But Fung's important analysis does not inspire a call for better report-card techniques; it calls instead for study of the social facts which render the reports, to date, so inefficacious.

1. H. Fung, Yee-Wei Lim, Soeren Mattke, Cheryl Damberg, and Paul G. Shekelle Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Ann Intern Med, Jan 2008; 148: 111 - 123.

2. Judith H. Hibbard. What Can We Say about the Impact of Public Reporting? Inconsistent Execution Yields Variable Results. Ann Intern Med, Jan 2008; 148: 160 - 161.

3. Mukamel DB, Weimer DL, Zwanziger J, Gorthy SF, Mushlin AI. Quality report cards, selection of cardiac surgeons, and racial disparities: a study of the publication of the New York State Cardiac Surgery Reports. Inquiry. 2004;41:435-46.

Conflict of Interest:

None declared

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