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November 2014 Vol 7, No 8 - Editorial
David B. Nash, MD, MBA
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I am frustrated. Despite more than 2 decades of personal involvement in the public reporting of healthcare outcomes and the widespread dissemination of these reports, there remains very little uptake by consumers of the information reported. Research contends that “most consumers do not believe quality varies from hospital to hospital, clinic to clinic, or physician to physician. Only 35% of adults think there are big differences in the quality of care among their local hospitals.”1

What has led to this state of affairs, and what can we do about it?

While I was still a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania in the mid-1980s, I had the opportunity to participate in what would become one of the first peer-reviewed journals focused on the outcomes of open heart surgery, the Journal of the American Medical Association. In a 1991 article in the journal, my colleagues and I reported on the differences in outcomes across 5 academic medical centers in Philadelphia, PA, for patients undergoing coronary artery bypass grafting (CABG) surgery.2 We discovered dramatic and significant differences in mortality across the 5 hospitals, while correcting for the severity of illness in multiple ways. In other words, patients undergoing CABG surgery at one hospital had nearly double or triple the mortality rate of those undergoing the same procedure at a different hospital that is literally down the street.2

Accompanying our article was an article from our colleagues at Dartmouth-Hitchcock Medical Center.3 Both articles, and an editorial by Donald M. Berwick, MD, MPP, President and Chief Executive Officer of the Institute for Healthcare Improvement,4 are often cited as the beginning of the consumerism movement in healthcare.

After the publication of those articles and contemporaneous with my move to Jefferson School of Population Health in 1990, I continued to work closely with the Pennsylvania Health Care Cost Containment Council (PHC4), one of the leading state-sponsored, tax-supported outcomes dissemination organizations in the nation. I still chair the technical advisory group of health services researchers and policy leaders who advise the PHC4 leaders.

I have also had the privilege of publishing more than a dozen peer-reviewed articles in major national journals focusing on state report cards and have led an effort that clearly demonstrates why the stakeholders that really use report cards to improve quality are the hospitals themselves rather than consumers, employers, or managed care plans.5 My articles were followed by 2 of the most widely read textbooks on quality and safety, with multiple chapters focused on public reporting.6,7

I remain perplexed as to why consumers do not use report cards. One reason may be that report cards are “too complicated” for the average consumer. Sure, it might be difficult to explain severity-adjusted morbidity and mortality, which are the cornerstones of most report cards. It is also understandable that the public may be befuddled by medical nomenclature and its related technical jargon. Another argument contends that consumers simply do not have the time to confer online en route to a hospital for a medical emergency. Some colleagues have suggested that consumers are simply not motivated to utilize a report card until they have a clinical problem, and by then they may be too preoccupied, too ill, or simply unaware as to how to find a report card.

More reasonable researchers contend that we simply are not giving consumers information they find valuable. Hibbard and colleagues, for example, have published the results of a study focused on managed care–related report cards that clearly demonstrate that most report cards describe the outcomes of procedures in ways that do not provide consumers with discriminatory power to enable them, for example, to select one provider over another.8 As a result, there is a growing body of literature that questions whether report cards ever improve quality.

Back to my frustration. In a post–Affordable Care Act world of transparency and accountability, how can we reconcile 20 years of underutilization of report cards, especially in an environment that is focused on the need for better information and increasing patient engagement in their own care? I am wrestling with this issue mightily.

Fortunately, recent work appears promising. In 2011, a national summit on public reporting was sponsored ­by the Agency for Healthcare Research and Quality (AHRQ), which brought together more than 125 individuals—believers and skeptics alike. The results of this summit were recently published in a supplement, in which attendees provided a “guided vision” for public reporting for consumers and made 10 critically important recommendations for the future.9

According to Hussey and colleagues, “by 2025—or ideally much sooner—consumers will access and appropriately use health care provider performance information in selecting providers. Specifically, consumers in every community in the United States will have ready access to comparable, accurate, meaningful, and actionable performance information on primary care physicians, specialists, hospitals, and ultimately the full spectrum of providers to enhance the quality of their decision making.”1 Wow! This is a beautiful guiding vision that is certainly worth endorsing.

How might we achieve this vision? The AHRQ investigators laid out a series of recommendations that include strengthening the demand for public policymakers, report sponsors, and consumer organizations to raise awareness about variation in healthcare quality.9 In other words, continue the work that our school has pioneered in disseminating the sorry state of affairs in our country, in which medical errors remain the third leading cause of death.10

The second AHRQ recommendation calls for identifying, developing, and testing a new generation of meaningful and scientifically sound measures that meet the consumers’ needs.9 This clearly is going to take a lot of additional research and will need to engage organizations such as the Joint Commission, the Leapfrog Group, the National Quality Forum, and many others.

Among the 8 remaining recommendations, let me highlight 3. Recommendation 4 calls for federal engagement with consumers to develop and test measures that are accessible, understandable, and usable.9 I hope that we will, as a nation, fund research that will lead to measures that make sense. Recommendation 7 calls for public and private consensus on the standards and data elements used in performance measures.9 We have been struggling with this lack of consensus in the policy community for nearly 30 years. How to achieve such consensus is not described in any additional detail.

Finally, recommendation 10 states, “public and private payers, through public policy and purchasing actions, should act in coordinated ways to financially support public reporting and collection of the underlying data.”9 I believe this tenth recommendation explicitly calls for the employer community to engage with providers to create a report card that makes sense. I certainly support this final recommendation and hope that there are opportunities for the different stakeholders to come together and implement this vision.

In conclusion, most of our readers would not dream of making a dinner reservation at a new restaurant without carefully reading its recent reviews on Yelp. Similarly, most of our peer group (in a social sense) would not purchase a large electronic item without checking Consumer Reports. Then why is it that the vast majority of even highly educated individuals do not access report cards, even cards that are readily available and based on good research, when it comes time to make a decision on healthcare purchasing?

I am hopeful that the recent publication by the AHRQ Task Force will garner a good deal of public attention. I believe that financial incentives that drive patients to high-value providers (those with a low error rate, who practice using the best available evidence and who, therefore, obtain good outcomes at a low cost) will be the cornerstone of any future public accountability system.

If you, too, are frustrated about this issue, please let me know. Better yet, tell me about a report card that you think makes sense. I am interested in your views, and you can reach me via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..

References
1. Hussey PS, Luft HS, McNamara P. Public reporting of provider performance at a crossroads in the United States: summary of current barriers and recommendations on how to move forward. Med Care Res Rev. 2014;71(5 suppl):5S-16S.
2. Williams SV, Nash DB, Goldfarb N. Differences in mortality from coronary artery bypass graft surgery at five teaching hospitals. JAMA. 1991;266:810-815.
3. O’Connor GT, Plume SK, Olmstead EM, et al; for the Northern New England Cardiovascular Disease Study Group. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. JAMA. 1991;266:803-809.
4. Berwick DM. The double edge of knowledge. JAMA. 1991;266:841-842.
5. Bentley JM, Nash DB. How Pennsylvania hospitals have responded to publicly released reports on coronary artery bypass graft surgery. Jt Comm J Qual Improv. 1998;24:40-49.
6. Nash DB, Clarke JL, Skoufalos A, Horowitz M, eds. Health Care Quality: The Clinician’s Primer. Tampa, FL: American College of Physician Executives; 2012.
7. Joshi MS, Ransom ER, Nash DB, Ransom SB, eds. The Healthcare Quality Book: Vision, Strategy, and Tools. 3rd ed. Chicago, IL: Health Administration Press; 2014.
8. Hibbard JH, Greene J, Daniel D. What is quality anyway? Performance reports that clearly communicate to consumers the meaning of quality of care. Med Care Res Rev. 2010;67:275-293.
9. Damberg CL, McNamara P, eds. Supplemental issue: informing the next generation of public reporting for consumers. Med Care Res Rev. 2014;71(5 suppl):3S-107S.
10. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9:122-128.

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