When outcomes make headlines, patient care improves
When outcomes make headlines, patient care improves
Bypass reports lead to lower mortality in NY, PA
If your outcomes were published in the newspaper, what would the headline say? Would a public ratings system cause you to work harder on quality improvement or to avoid sicker patients and more complicated cases?
The performance of physicians, hospitals, and health plans has become hot news, sometimes even a front-page story. While ratings systems provoke concerns about fairness, outcomes experts say making the information public ultimately leads to better health care. Physicians can expect to see more comparative data made public as this trend accelerates around the country.
In New York state, where the Department of Health has been calculating risk-adjusted, surgeon-specific data on coronary artery bypass graft (CABG) surgery since 1989, some physicians with a low volume of these procedures stopped performing them. Although the average patient became sicker over the years, mortality rates declined by 21% from 1989 to 1992, according to health department reports.The risk-adjusted mortality rate during that period dropped by 41%.1
After four years of coronary bypass reports in Pennsylvania, mortality rates have dropped by 26%. And in Cleveland, consumers can buy a summary report from the Cleveland Health Quality Choice Coalition for $4 that compares hospitals, including nursing and physician care. Local newspapers also publish comparative charts. In response, physicians focus on everything from shorter waiting times to care pathways. Mortality rates for selected medical diagnoses, including congestive heart failure, stroke, and pneumonia, have declined at Cleveland-area hospitals since 1992, as has the average hospital length of stay. (See chart on p. 2.)
"This approach [of publishing outcomes data] produces results by bringing peer pressure to bear on hospitals that might not have paid attention otherwise," says Mark R. Chassin, MD, MPH, MPP, chairman and professor in the department of health policy at Mt. Sinai School of Medicine in New York City and former commissioner of the New York state Department of Health.
Physicians also are concerned about improving their performance as compared to their peers. "That is an essential ingredient to explain [the outcomes project’s] success," he says.
Public reporting of outcomes lies at the heart of the movement toward "managed competition," in which consumers choose their provi ders or health plans based on comparative information. One example of that concept in action: This month, employees of organizations participating in an employer coalition in Minnesota will make benefit choices based on provider groups, rather than on insurance carrier, through a special balloting system. The employees received a booklet detailing outcomes data for the participating provider groups to help in the selection. (For more information on the Minnesota system, see Patient Satisfaction & Outcomes Management, December 1996, pp. 133-134.)
Business and health care coalitions hope that by informing consumers about cost and quality, they can influence providers to improve both. (See related story on managed competition, p. 4.)
"[Consumer-oriented reporting] highlights those who are doing well, and it puts pressure in a public way on those who aren’t," says Joe Martin, press secretary of the Pennsylvania Health Care Cost Containment Council in Harrisburg. "Hopefully, it improves the quality of care for everyone."
A recent report by the Pennsylvania agency caused a stir when it showed that HMOs in the southeastern region of the state had higher-than-expected mortality rates for people hospitalized with a heart attack. "Belong to an HMO? Your chances of surviving a heart attack are lower," read the headline in the Philadelphia Daily News. While the report didn’t name individual HMOs, that information is coming in the agency’s next report, Martin says.
The Pennsylvania agency has issued physician-specific reports on CABG surgery, a "hospital effectiveness report" on 57 diagnosis-related groups (DRGs), and a hospital-specific report on cesarean sections. In addition to a decline in mortality rates from CABG surgery, "we’ve also seen a significant slowing down of price increases," Martin says. In 1991, the average charge for bypass surgery increased by 10% over the previous year, he says. By 1993, charges dropped 4.5% compared to the previous year.
"We know that hospitals feel that they need to respond to this [information]," Martin says. "We’ve certainly seen examples of hospital reports in which hospitals have said they are cutting their prices or holding the line as a result of these reports."
In fact, when agencies or health care coalitions publish outcomes data for the public, the methodologies are often attacked and the projects can be fraught with controversy.
"There are lots of critics, some well-intentioned, some not, some well-informed, some clearly not," says Chassin of the New York outcomes program. Different constituencies, from physicians to the public, need to be educated about the data collection, he says.
In some cases, program officials have to investigate and answer specific charges. For example, some critics said the New York mortality rates dropped because physicians refused to see the sickest patients and those patients ended up going out of state for their surgery.
That charge is simply not true, Chassin says. "There is absolutely no credible data to suggest that high-risk patients are being avoided," he says. "More than half the doctors and hospitals do better [in the risk-adjusted reports] because they operate on high-risk patients because they do such a good job."
Coalitions and agencies collecting outcomes information generally maintain technical advisory groups of physicians to provide advice, and they consider factors that physicians say might influence patient risk.
It’s common for the medical community to react defensively when the Pennsylvania agency addresses a new outcomes area, Martin says. "By trying to have a cooperative relationship with the medical community and respond to their concerns when they’re appropriate and legitimate, we find over time that the environment becomes more supportive," he says.
One legitimate concern involves the quality of data used for analysis. Data from clinical records provides the best information for risk adjustment, says Ed Hannan, PhD, professor and chair of the department of health policy management and behavior at the State University of New York-Albany School of Public Health. But to save money, some agencies may use administrative or reimbursement-related information.
For example, an administrative database wouldn’t distinguish between a bypass patient who came to the hospital while suffering a heart attack and a patient who had a heart attack during the procedure, says Hannan, who is a consultant to the health department’s program. One case is a comorbidity, the other an adverse outcome, he says.
Despite the difficulties of collecting, analyzing, and publicly reporting outcomes information, the projects are gathering steam around the country. Overall, the impact has been positive, as measured in improved outcomes and satisfaction and from an educational perspective, outcomes experts say.
"Between the occasional horror stories reported by the media [of negative outcomes] and the feel-good promotional material by the health plans themselves, there’s a role for providing objective and credible information that people can use to make some decisions about what providers to go to and what health plans to join," says Martin.
References
1. Chassin MR, Hannan EL, DeBuono BA. Benefits and hazards of reporting medical outcomes publicly. N Engl J Med 1996; 334:394-398.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.