Public release of performance data in changing the behaviour of healthcare consumers, professionals or organisations

[How do Surgical Patients Choose their Hospital? A Cross-sectional Study]

BACKGROUND

Free hospital choice is promoted in health policy through public quality reporting. Previous studies on hospital choice mostly survey patients for specific elective procedures. This study examines all full inpatient surgical patients and compares them to those in other specialties. Research questions are: How many patients make their own decisions about the hospital? How much time do they have before admission? Where do they obtain information and what are their important decision criteria?

MATERIALS AND METHODS

This study evaluates cross-sectional primary data on hospital choice collected by questionnaire from 1925 consecutively hospitalised patients from 11 medical specialties and 3 levels of care, including 438 surgical patients from 6 general surgery departments.

RESULTS

Three quarters of surgical patients decide on the hospital themselves. Their own previous experience with the hospital is an important source of information and decision-making criterion for a good half of the patients, along with relatives and outpatient treatment providers as well as the hospital reputation.

CONCLUSION

Many surgical patients decide in favour of a hospital because of the trust they have built up through previous treatment in the hospital, which they experience as satisfactory. The professional quality of treatment is thus the greatest impact factor on patients, their relatives and outpatient treatment providers. It is important to actively and specifically address and clarify possible dissatisfaction on the part of the patient before discharge.

Reporting unit context data to stakeholders in long-term care: a practical approach

Background

The importance of reporting research evidence to stakeholders in ways that balance complexity and usability is well-documented. However, guidance for how to accomplish this is less clear. We describe a method of developing and visualising dimension-specific scores for organisational context (context rank method). We explore perspectives of leaders in long-term care nursing homes (NHs) on two methods for reporting organisational context data: context rank method and our traditionally presented binary method—more/less favourable context.

Methods

We used a multimethod design. First, we used survey data from 4065 healthcare aides on 290 care units from 91 NHs to calculate quartiles for each of the 10 Alberta Context Tool (ACT) dimension scores, aggregated at the care unit level based on the overall sample distribution of these scores. This ordinal variable was then summed across ACT scores. Context rank scores were assessed for associations with outcomes for NH staff and for quality of care (healthcare aides’ instrumental and conceptual research use, job satisfaction, rushed care, care left undone) using regression analyses. Second, we used a qualitative descriptive approach to elicit NH leaders’ perspectives on whether the methods were understandable, meaningful, relevant, and useful. With 16 leaders, we conducted focus groups between December 2017 and June 2018: one in Nova Scotia, one in Prince Edward Island, and one in Ontario, Canada. Data were analysed using content analysis.

Results

Composite scores generated using the context rank method had positive associations with healthcare aides’ instrumental research use (p < .0067) and conceptual research use and job satisfaction (p < .0001). Associations were negative between context rank summary scores and rushed care and care left undone (p < .0001). Overall, leaders indicated that data presented by both methods had value. They liked the binary method as a starting point but appreciated the greater level of detail in the context rank method.

Conclusions

We recommend careful selection of either the binary or context rank method based on purpose and audience. If a simple, high-level overview is the goal, the binary method has value. If improvement is the goal, the context rank method will give leaders more actionable details.

Black-White disparities in maternal in-hospital mortality according to teaching and Black-serving hospital status

BACKGROUND

Maternal mortality is higher among Black than White people in the United States. Whether Black-White disparities in maternal in-hospital mortality during the delivery hospitalization vary across hospital types (Black-serving vs nonBlack-serving and teaching vs nonteaching) and whether overall maternal mortality differs across hospital types is not known.

OBJECTIVE

The aims of this study were to determine whether risk-adjusted Black-White disparities in maternal mortality during the delivery hospitalization vary by hospital types (this is analysis of disparities in mortality within hospital types) and compare risk-adjusted in-hospital maternal mortality among Black-serving and nonBlack-serving teaching and nonteaching hospitals regardless of race (this is an analysis of overall mortality across hospital types).

STUDY DESIGN

We performed a population-based, retrospective cohort study of 5,679,044 deliveries among Black (14.2%) and White patients (85.8%) in 3 states (California, Missouri, and Pennsylvania) from 1995 to 2009. A hospital discharge disposition of "death" defined maternal in-hospital mortality. Black-serving hospitals had at least 7% Black obstetrical patients (top quartile). We performed risk adjustment by calculating expected death rates using predictions from logistic regression models incorporating sociodemographics, rurality, comorbidities, multiple gestations, gestational age at delivery, year, state, and mode of delivery. We calculated risk-adjusted risk ratios of mortality by comparing observed-to-expected ratios among Black and White patients within hospital types and then examined mortality across hospital types, regardless of patient race. We quantified the proportion of Black-White disparities in mortality attributable to delivering in Black-serving hospitals using causal mediation analysis.

RESULTS

There were 330 maternal deaths among 5,679,044 patients (5.8 per 100,000). Black patients died more often (11.5 per 100,000) than White patients (4.8 per 100,000) (relative risk, 2.38; 95% confidence interval, 1.89-2.98). Examination of Black-White disparities revealed that after risk adjustment, Black patients had significantly greater risk of death (adjusted relative risk, 1.44; 95% confidence interval, 1.17-1.79) and that the disparity was similar within each of the hospital types. Comparison of mortality, regardless of race, across hospital types revealed that among teaching hospitals, mortality was similar in Black-serving and nonBlack-serving hospitals. However, among nonteaching hospitals, mortality was significantly higher in Black-serving vs nonBlack-serving hospitals (adjusted relative risk, 1.47; 95% confidence interval, 1.15-1.87). Notably, 53% of Black patients delivered in nonteaching, Black-serving hospitals compared with just 19% of White patients. Among nonteaching hospitals, 47% of Black-White disparities in maternal in-hospital mortality were attributable to delivering at Black-serving hospitals.

CONCLUSION

Maternal in-hospital mortality during the delivery hospitalization among Black patients is more than double that of White patients. Our data suggest this disparity is caused by excess mortality among Black patients within each hospital type, in addition to excess mortality in nonteaching, Black-serving hospitals where most Black patients deliver. Addressing downstream effects of racism to achieve equity in maternal in-hospital mortality will require transparent reporting of quality metrics by race to reduce differential care and outcomes within hospital types, improvements in care delivery at Black-serving hospitals, overcoming barriers to accessing high-quality care among Black patients, and eventually desegregation of healthcare.

Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.

Mechanisms and impact of public reporting on physicians and hospitals' performance: A systematic review (2000-2020)

BACKGROUND

Public performance reporting (PPR) of physician and hospital data aims to improve health outcomes by promoting quality improvement and informing consumer choice. However, previous studies have demonstrated inconsistent effects of PPR, potentially due to the various PPR characteristics examined. The aim of this study was to undertake a systematic review of the impact and mechanisms (selection and change), by which PPR exerts its influence.

METHODS

Studies published between 2000 and 2020 were retrieved from five databases and eight reviews. Data extraction, quality assessment and synthesis were conducted. Studies were categorised into: user and provider responses to PPR and impact of PPR on quality of care.

RESULTS

Forty-five studies were identified: 24 on user and provider responses to PPR, 14 on impact of PPR on quality of care, and seven on both. Most of the studies reported positive effects of PPR on the selection of providers by patients, purchasers and providers, quality improvement activities in primary care clinics and hospitals, clinical outcomes and patient experiences.

CONCLUSIONS

The findings provide moderate level of evidence to support the role of PPR in stimulating quality improvement activities, informing consumer choice and improving clinical outcomes. There was some evidence to demonstrate a relationship between PPR and patient experience. The effects of PPR varied across clinical areas which may be related to the type of indicators, level of data reported and the mode of dissemination. It is important to ensure that the design and implementation of PPR considered the perspectives of different users and the health system in which PPR operates in. There is a need to account for factors such as the structural characteristics and culture of the hospitals that could influence the uptake of PPR.

Quality assurance in primary total hip arthroplasty

OBJECTIVE

To compare two different methods of clinical outcomes documentation and investigate the potential impact of a quality assurance program.

METHODS

Data on primary hip arthroplasties conducted between 2004 and 2014 were prospectively collected and analyzed.

RESULTS

A total of 262/3395 patients suffered a postoperative complication. A reduction of complication rate was observed between 2010 and 2014. A significant difference between the two documentation methods was found in: "cardiovascular complications", "hematoma and postoperative hemorrhage" and "reintervention". Finally, the "normalized length of hospital stay" predicted the occurrence of complications.

CONCLUSION

Reduction of the incidence of complications through time may be attributed to accumulated surgical experience.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Appropriateness, effectiveness and safety of care delivered in Canadian hospitals: a longitudinal assessment on the utility of publicly reported performance trend data between 2012-2013 and 2016-2017

OBJECTIVES

To assess the utility of publicly reported performance trend results of Canadian hospitals (by hospital size/type and jurisdiction).

DESIGN

Longitudinal observational study.

SETTING

489 hospitals in Canada between fiscal years 2012-2013 and 2016-2017.

PARTICIPANTS

Analysis focused on indicator results of individual Canadian hospitals.

PRIMARY AND SECONDARY OUTCOMES

Eight outcome indicators of hospital performance: in-hospital mortality (2), readmissions (4) and adverse events (2). Performance trend outcomes of improving, weakening or no change over time. Comparators in performance by hospital size/type of above, below or same as average.

RESULTS

At the national level, between 2012-2013 and 2016-2017, Canadian hospitals largely reduced in-hospital mortality: hospital deaths (hospital standardised mortality ratio) -9%; hospital deaths following major surgery -11.1%. Conversely, readmission to hospital increased nationwide: medical 1.5%; obstetric 5%; patients aged 19 years and younger 4.6% and surgical 3%. In-hospital sepsis declined -7.1%. Approximately 10% of the 489 hospitals in this study had a trend of improving performance over time (n=49) in one or more indicators, and a similar number showed a weakening performance over time (n=52). Roughly half of the hospitals in this study (n=224) had no change in performance over time for at least four out of the eight indicators. No single hospital had an improving or weakening trend in more than two indicators. Teaching and larger-sized hospitals showed a higher ratio of improving performance compared with smaller-sized hospitals.

CONCLUSIONS

Analysis of Canadian hospital performance through eight indicators shows improvement of in-hospital mortality and in-hospital sepsis, but rising rates of readmissions. Subdividing the analysis by hospital size/type shows greater instances of improvement in teaching and larger-sized hospitals. There is no clear pattern of a particular province/territory with a significant number of hospitals with improving or weakening trends. The overall assessment of trends of improving and weakening as presented in this study can be used more systematically in monitoring progress.

Knowledge translation strategies for dissemination with a focus on healthcare recipients: an overview of systematic reviews

BACKGROUND

While there is an ample literature on the evaluation of knowledge translation interventions aimed at healthcare providers, managers, and policy-makers, there has been less focus on patients and their informal caregivers. Further, no overview of the literature on dissemination strategies aimed at healthcare users and their caregivers has been conducted. The overview has two specific research questions: (1) to determine the most effective strategies that have been used to disseminate knowledge to healthcare recipients, and (2) to determine the barriers (and facilitators) to dissemination of knowledge to this group.

METHODS

This overview used systematic review methods and was conducted according to a pre-defined protocol. A comprehensive search of ten databases and five websites was conducted. Both published and unpublished reviews in English, Spanish, or Portuguese were included. A methodological quality assessment was conducted; low-quality reviews were excluded. A narrative synthesis was undertaken, informed by a matrix of strategy by outcome measure. The Health System Evidence taxonomy for "consumer targeted strategies" was used to separate strategies into one of six categories.

RESULTS

We identified 44 systematic reviews that describe the effective strategies to disseminate health knowledge to the public, patients, and caregivers. Some of these reviews also describe the most important barriers to the uptake of these effective strategies. When analyzing those strategies with the greatest potential to achieve behavioral changes, the majority of strategies with sufficient evidence of effectiveness were combined, frequent, and/or intense over time. Further, strategies focused on the patient, with tailored interventions, and those that seek to acquire skills and competencies were more effective in achieving these changes. In relation to barriers and facilitators, while the lack of health literacy or e-literacy could increase inequities, the benefits of social media were also emphasized, for example by widening access to health information for ethnic minorities and lower socioeconomic groups.

CONCLUSIONS

Those interventions that have been shown to be effective in improving knowledge uptake or health behaviors should be implemented in practice, programs, and policies-if not already implemented. When implementing strategies, decision-makers should consider the barriers and facilitators identified by this overview to ensure maximum effectiveness.

PROTOCOL REGISTRATION

PROSPERO: CRD42018093245.

Public Reporting of Percutaneous Coronary Intervention Outcomes: Moving Beyond the Status Quo

Importance

More than 20 years have passed since public reporting of percutaneous coronary intervention (PCI) outcomes first began in New York State, but reporting remains a polarizing issue.

Observations

Advocates of public reporting point to the strong incentive that public disclosure of outcomes data provides for institutions and clinicians to improve clinical care and to the importance of enabling patients to make informed choices about their care. Critics highlight the methodological challenges that impede fair and accurate assessments of care quality as well as reporting's unintended consequences. Public reporting of PCI outcomes has only been implemented in 5 states, but reporting efforts for multiple conditions and procedures are now proliferating nationally, propelled by the notion that transparency improves the quality of health care and fosters trust in health care institutions. Careful evaluation of the evidence to date for PCI in particular, however, suggests that enthusiasm for such efforts should be tempered.

Conclusions and Relevance

Public reporting has not achieved its primary objectives. Policy makers should consider variations of reporting that might strengthen care quality, empower patients, and mitigate undesirable repercussions.

Spatial analysis of factors influencing choice of paediatric practice for mothers from low-income and minority populations

AIM

Publicly reported quality data theoretically enable parents to choose higher-performing paediatric practices. However, little is known about how parents decide where to seek paediatric care. We explored the relationship between geographic factors, care quality and choice of practice to see if the decision-making process could be described in terms of a 'gravity model' of spatial data.

METHODS

In the context of a randomised controlled trial, we used a geographic information system to calculate flow volume between practice locations and participants' homes, to locate subjects within a census tract, to determine distances between points and to perform exploratory mapping. Generalised linear modelling was then used to determine whether the data fit a gravity model, which is a spatial model that evaluates factors impacting travel from one set of locations to another.

RESULTS

A total of 662 women and 52 paediatric practices were included in the analysis. Proximity of a practice to home was the most important factor in choosing a practice (Z = -15.01, P < 0.001). Practice size was important to a lesser extent, with larger practices more likely to be chosen (Z = 8.96, P < 0.001). A practice's performance on quality measures was associated with choice only for women who had received an intervention to increase use of quality data (Z = 2.51, P < 0.05).

CONCLUSIONS

The gravity model and the concept of flow can help explain the choice of paediatric practice in a predominantly low-income, racially ethnic minority (non-White) urban population. This has important ramifications for the potential impact of publicly reported quality data.

The Impact of Public Performance Reporting on Market Share, Mortality, and Patient Mix Outcomes Associated With Coronary Artery Bypass Grafts and Percutaneous Coronary Interventions (2000-2016): A Systematic Review and Meta-Analysis

Supplemental Digital Content is available in the text.

Objective:

Public performance reporting (PPR) of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) outcomes aim to improve the quality of care in hospitals, surgeons and to inform consumer choice. Past CABG and PCI studies have showed mixed effects of PPR on quality and selection. The aim of this study was to undertake a systematic review and meta-analysis of the impact of PPR on market share, mortality, and patient mix outcomes associated with CABG and PCI.

Methods:

Six online databases and 8 previous reviews were searched for the period 2000–2016. Data extraction, quality assessment, systematic critical synthesis, and meta-analysis (where possible) were carried out on included studies.

Results:

In total, 22 relevant articles covering mortality (n=19), patient mix (n=14), and market share (n=6) outcomes were identified. Meta-analyses showed that PPR led to a near but not significant reduction in short-term mortality for both CABG and PCI. PPR on CABG showed a positive effect on market share for hospitals (3 of 6 studies) and low-performing surgeons (2 of 2 studies). Five of 6 PCI studies found that high-risk patients were less likely to be treated in States with PPR.

Conclusions:

There is some evidence that PPR reduces mortality rates in CABG/PCI-treated patients. The significance of there being no strong evidence, in the period 2000–2016, should be considered. There is need for both further development of PPR practice and further research into the intended and unintended consequences of PPR.

Health Care Policy and Outcomes after Colon and Rectal Surgery: What Is the Bigger Picture?-Cost Containment, Incentivizing Value, Transparency, and Centers of Excellence

Early in the 21st century, the costs of health care in the United States have spiraled out of control, where the per capita spending is $9,237 per person-the highest in the world. By 2020, an estimated 20% of GDP will be spent on health care. The issue of cost and quality is now becoming a national crisis, with ∼50% of hospitals losing money on clinical operations, forcing closure of essential critical access hospitals, and forcing health care workers to relocate or change professions. This crisis will only worsen with the graying of America, as an estimated 17% of Americans will be over the age of 65 years by the year 2020. The policy and financial structures on which these changes are based are important factors of which practicing surgeons should be aware. This review discusses recent national health care policy reform and specific topics including cost-containment legislation, value-based incentives and penalties, transparency, and centers of excellence in colorectal surgery.

Hospital Choice for Cataract Treatments: The Winner Takes Most

Background: Transparency in quality of care is an increasingly important issue in healthcare. In many international healthcare systems, transparency in quality is crucial for health insurers when purchasing care on behalf of their consumers, for providers to improve the quality of care (if necessary), and for consumers to choose their provider in case treatment is needed. Conscious consumer choices incentivize healthcare providers to deliver better quality of care. This paper studies the impact of quality on patient volume and hospital choice, and more specifically whether high quality providers are able to attract more patients.

Methods: The dataset covers the period 2006-2011 and includes all patients who underwent a cataract treatment in the Netherlands. We first estimate the impact of quality on volume using a simple ordinary least squares (OLS), second we use a mixed logit to determine how patients make trade-offs between quality, distance and waiting time in provider choice.

Results: At the aggregate-level we find that, a one-point quality increase, on a scale of one to a hundred, raises patient volume for the average hospital by 2-4 percent. This effect is mainly driven by the hospital with the highest quality score: the effect halves after excluding this hospital from the dataset. Also at the individual-level, all else being equal, patients have a stronger preference for the hospital with the highest quality score, and appear indifferent between the remaining hospitals.

Conclusion: Our results suggest that the top performing hospital is able to attract significantly more patients than the remaining hospitals. We find some evidence that a small share of consumers may respond to quality differences, thereby contributing to incentives for providers to invest in quality and for insurers to take quality into account in the purchasing strategy.

Basic Accountability to Stop Ill-Treatment (BASI); Study Protocol for a Cluster Randomized Controlled Trial in Rural Tanzania

Background: Poor health system experiences negatively affect the lives of poor people throughout the world. In East Africa, there is a growing body of evidence of poor quality care that in some cases is so poor that it is disrespectful or abusive. This study will assess whether community feedback through report cards (with and without non-financial rewards) can improve patient experience, which includes aspects of patient dignity, autonomy, confidentiality, communication, timely attention, quality of basic amenities, and social support.

Methods/Design: This cluster-randomized controlled study will randomize 75 primary health care facilities in rural Pwani Region, Tanzania to one of three arms: private feedback (intervention), social recognition reward through public reporting (intervention), or no feedback (control). Within both intervention arms, we will give the providers at the study facilities feedback on the quality of patient experience the facility provides (aggregate results from all providers) using data from patient surveys. The quality indicators that we report will address specific experiences, be observable by patients, fall into well-identified domains of patient experience, and be within the realm of action by healthcare providers. For example, we will measure the proportion of patients who report that providers definitely “explained things in a way that was easy to understand.” This feedback will be delivered by a medical doctor to all the providers at the facility in a small group session. A formal discussion guide will be used. Facilities randomized to the social recognition intervention reward arm will have two additional opportunities for social recognition. First, a poster that displays their achieved level of patient experience will be publicly posted at the health facility and village government offices. Second, recognition from senior officials at the local NGO and/or the Ministry of Health will be given to the facility with the best or most-improved patient experience ratings at endline. We will use surveys with parents/guardians of sick children to measure patient experience, and surveys with healthcare providers to assess potential mechanisms of effect.

Conclusion: Results from this study will provide evidence for whether, and through what mechanisms, patient reported feedback can affect interpersonal quality of care.

Pan African Clinical Trials Registry (PACTR): 201710002649121 Protocol version 7, November 8, 2017

Impact of public release of performance data on the behaviour of healthcare consumers and providers

BACKGROUND

It is becoming increasingly common to publish information about the quality and performance of healthcare organisations and individual professionals. However, we do not know how this information is used, or the extent to which such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers, and purchasers.

OBJECTIVES

To estimate the effects of public release of performance data, from any source, on changing the healthcare utilisation behaviour of healthcare consumers, providers (professionals and organisations), and purchasers of care. In addition, we sought to estimate the effects on healthcare provider performance, patient outcomes, and staff morale.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trials registers on 26 June 2017. We checked reference lists of all included studies to identify additional studies.

SELECTION CRITERIA

We searched for randomised or non-randomised trials, interrupted time series, and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or professionals. Each study had to report at least one main outcome related to selecting or changing care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers, and healthcare purchasers), performance data, main outcomes (choice of healthcare provider, and improvement by means of changes in care), and other outcomes (awareness, attitude, knowledge of performance data, and costs). Given the substantial degree of clinical and methodological heterogeneity between the studies, we presented the findings for each policy in a structured format, but did not undertake a meta-analysis.

MAIN RESULTS

We included 12 studies that analysed data from more than 7570 providers (e.g. professionals and organisations), and a further 3,333,386 clinical encounters (e.g. patient referrals, prescriptions). We included four cluster-randomised trials, one cluster-non-randomised trial, six interrupted time series studies, and one controlled before-after study. Eight studies were undertaken in the USA, and one each in Canada, Korea, China, and The Netherlands. Four studies examined the effect of public release of performance data on consumer healthcare choices, and four on improving quality.There was low-certainty evidence that public release of performance data may make little or no difference to long-term healthcare utilisation by healthcare consumers (3 studies; 18,294 insurance plan beneficiaries), or providers (4 studies; 3,000,000 births, and 67 healthcare providers), or to provider performance (1 study; 82 providers). However, there was also low-certainty evidence to suggest that public release of performance data may slightly improve some patient outcomes (5 studies, 315,092 hospitalisations, and 7502 providers). There was low-certainty evidence from a single study to suggest that public release of performance data may have differential effects on disadvantaged populations. There was no evidence about effects on healthcare utilisation decisions by purchasers, or adverse effects.

AUTHORS' CONCLUSIONS

The existing evidence base is inadequate to directly inform policy and practice. Further studies should consider whether public release of performance data can improve patient outcomes, as well as healthcare processes.

Public reporting of antipsychotic prescribing in nursing homes: population-based interrupted time series analyses

Background

Although sometimes appropriate, antipsychotic medications are associated with increased risk of significant adverse events. In 2014, a series of newspaper articles describing high prescribing rates in nursing homes in Ontario, Canada, garnered substantial interest. Subsequently, an online public reporting initiative with home-level data was launched. We examined the impact of these public reporting interventions on antipsychotic prescribing in nursing homes.

Methods

Time series analysis of all nursing home residents in Ontario, Canada, between 1 October 2013 and 31 March 2016. The primary outcome was the proportion of residents prescribed antipsychotics each month. Balance measures were prescriptions for common alternative sedating agents (benzodiazepines and/or trazodone). We used segmented regression to assess the effects on prescription trends of the newspaper articles and the online home-level public reporting initiative.

Results

We included 120 009 nursing home resident admissions across 636 nursing homes. Following the newspaper articles, the proportion of residents prescribed an antipsychotic decreased by 1.28% (95% CI 1.08% to 1.48%) and continued to decrease at a rate of 0.2% per month (95% CI 0.16% to 0.24%). The online public reporting initiative did not alter this trend. Over 3 years, there was a net absolute reduction in antipsychotic prescribing of 6.0% (95% CI 5.1% to 6.9%). Trends for benzodiazepine prescribing did not change as substantially during the period of observation. Trazodone use has been gradually increasing, but its use did not change abruptly at the time of the mass media report or the public reporting initiative.

Interpretation

The rapid impact of mass media on prescribing suggests both an opportunity to use this approach to invoke change and a warning to ensure that such reporting occurs responsibly.

Hospital quality reporting and improvement in quality of care for patients with acute myocardial infarction

Background

Although public reporting of hospital performance is becoming common, it remains uncertain whether public reporting leads to improvement in clinical outcomes. This study was conducted to evaluate whether enrollment in a quality reporting project is associated with improvement in quality of care for patients with acute myocardial infarction.

Methods

We conducted a quasi-experimental study using hospital census survey and national inpatient database in Japan. Hospitals enrolled in a ministry-led quality reporting project were matched with non-reporting control hospitals by one-to-one propensity score matching using hospital characteristics. Using the inpatient data of acute myocardial infarction patients hospitalized in the matched hospitals during 2011–2013, difference-in-differences analyses were conducted to evaluate the changes in unadjusted and risk-adjusted in-hospital mortality rates over time that are attributable to intervention.

Results

Matching between hospitals created a cohort of 30,220 patients with characteristics similar between the 135 reporting and 135 non-reporting hospitals. Overall in-hospital mortality rates were 13.2% in both the reporting and non-reporting hospitals. There was no significant association between hospital enrollment in the quality reporting project and change over time in unadjusted mortality (OR, 0.98; 95% CI, 0.80–1.22). In 28,168 patients eligible for evaluation of risk-adjusted mortality, enrollment was also not associated with change in risk-adjusted mortality (OR, 0.98; 95% CI, 0.81–1.17).

Conclusions

Enrollment in the quality reporting project was not associated with short-term improvement in quality of care for patients with acute myocardial infarction. Additional efforts may be necessary to improve quality of care.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3330-4) contains supplementary material, which is available to authorized users.

The use of public performance reporting by general practitioners: a study of perceptions and referral behaviours

Background

Public performance reporting (PPR) of hospital data aims to improve quality of care in hospitals and to inform consumer choice. In Australia, general practitioners (GPs) are gatekeepers to secondary care with patients requiring their referral for non-emergency access. Despite their intermediary role, GPs have been generally overlooked as potential users of PPR of hospital data, with the majority of the PPR research focussing on consumers, surgeons and hospitals.

Methods

We examined the use of PPR of hospital data by GPs when referring patients to hospitals. Semi-structured interviews were conducted with 40 GPs, recruited via the Victorian Primary Care Practice-Based Research Network and GP teaching practices in Victoria, Australia. The interviews were recorded, transcribed and analysed thematically.

Results

We found that the majority of GPs did not use PPR when referring patients to hospitals. Instead, they relied mostly on informal sources of information such as their own or patients’ previous experiences. Barriers that prevented GPs’ use of PPR in their decision making included: lack of awareness and accessibility; perceived lack of data credibility; restrictive geographical catchments for certain hospitals; limited choices of public hospitals in regional and rural areas; and no mandatory PPR for private hospitals.

Conclusions

Our findings suggest that lack of PPR awareness prevented GPs from using it in their referral practice. As gatekeepers to secondary care, GPs are in a position to guide patients in their treatment decisions and referrals using available PPR data. We suggest that there needs to be greater involvement by GPs in the development of hospital performance and quality indicators in Australia if GPs are to make greater use of them. The indicators require further development before GPs perceive them as valid, credible, and of use for informing their referral practices.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0719-4) contains supplementary material, which is available to authorized users.

Physician-Specific Variability in Spine Fusion Patients

BACKGROUND

It is often assumed that each surgeon's patient population is similar to that of his or her peers. Differences in patient characteristics naturally may lead to diverse outcomes. To date, the variability of individual surgeons' patient populations has not been adequately characterized. The purpose of this study is to describe the variation in physician-specific patient characteristics among surgeons performing spine fusion surgery at a large, urban academic medical center.

METHODS

We analyzed administrative data from a single institution for spine fusion surgery from 2009 to 2013. There were 6585 primary and 362 revision cases of spine fusion performed within this time period. Variability between surgeons and their respective patient populations was compared using descriptive statistics.

RESULTS

The mean annual percentage of primary fusion patients with diabetes mellitus ranged from 0 to 16.17% (mean ± SD, 7.79% ± 3.96%) but constituted anywhere from 0 to 41.58% (mean ± SD, 8.15% ± 12.09%) of revision fusions. The mean annual percentage of primary fusion patients who were obese ranged from 0 to 9% (mean ± SD, 2.95% ± 2.7%), and 0 to 25% in revision cases (mean ± SD, 3.43% ± 6.43%). The annual mean percentage of patients with American Society of Anesthesiologists (ASA) scores greater than 3 ranged from 8.8% to 44.43% (mean ± SD, 20.42% ± 8.85%) in primary fusions and 0 to 100% (mean ± SD, 32.79% ± 23.47%) in revision fusions.

CONCLUSION

There was a large amount of variability among surgeons' patient populations when looking at characteristics such as obesity, diabetes, and ASA scores >3. These factors have been shown to impact patient outcomes. The variability in the patient populations of individual surgeons' practices even within the same medical center must be taken into account when evaluating physician specific outcomes and quality of care.

Hospital choice in Germany from the patient's perspective: a cross-sectional study

Background

In many countries health policy encourages patients to choose their hospital, preferably by considering information of performance reports. Previous studies on hospital choice mainly have focused on patients undergoing elective surgery. This study examined a representative sample of hospital inpatients across disciplines and treatment interventions in Germany. Its research questions were: How many patients decide where to go for hospital treatment? How much time do patients have before admission? Which sources of information do they use, and which criteria are relevant to their decision?

Methods

Cross-sectional observational study covering 1925 inpatients of 46 departments at 17 hospitals in 2012. The stratified survey comprised 11 medical disciplines (internal medicine, gynaecology, obstetrics, paediatrics, psychiatry, orthopaedics, neurology, urology, ENT and geriatrics) on 3 hospital care levels representing 91.9% of all hospital admissions to inpatient care in Germany in 2012. The statistical analysis calculated the frequency distributions and 95% confidence intervals of characteristics related to the hospital choice.

Results

63.0% [60.9–65.2] of patients in Germany chose the hospital themselves, but only 21.1% [19.3–22.9] had more than one week to decide prior to admission. Major sources of information were personal knowledge of hospitals, relatives, outpatient health professionals and the Internet. Main criteria for the decision were personal experience with a hospital, recommendations from relatives and providers of outpatient services, a hospital’s reputation and distance from home. Specific quality information as provided by performance reports were of secondary importance.

Conclusions

A majority of patients in the German health system choose their hospital freely. Providers of outpatient health care can have an important “agent” function in the quality-oriented hospital choice especially for patients with little time prior to admission and those who do not decide themselves. Hospitals have an impact on patients’ future hospital choices by the treatment experience they provide to patients.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2712-3) contains supplementary material, which is available to authorized users.

A proposal for thyroid surgery: criteria to identify the references of endocrine surgery

Indicators of effectiveness and quality of care are needed to improve the outcomes in many surgical fields. International and national studies in thyroid surgery have not clearly documented an association between number of cases and outcome quality, but it is essential for the figure of a highly experienced surgeon, able to provide proof of positive outcomes. Therefore, we try to underline the structural and technical requirements in thyroid surgery. Moreover, the need for an accreditation program is outlined.

Governance arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision-making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of governance arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out-of-pocket payments, cost-effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).Overall, we found desirable effects for the following interventions on at least one outcome, with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Decision-making about what is covered by health insurance- Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence). Stakeholder participation in policy and organisational decisions- Participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence).- Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate-certainty evidence). Disclosing performance information to patients and the public- Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence).- Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Investigators have evaluated a wide range of governance arrangements that are relevant for low-income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate-certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.

Hospital quality variation matters - A time-trend and cross-section analysis of outcomes in German hospitals from 2006 to 2014

Awareness of care variation and associated differences in outcome quality is important for patients to recognize and leverage the benefits of hospital choice and for policy makers, providers, and suppliers to adapt initiatives to improve hospital quality of care. We examine panel data on outcome quality in German hospitals between 2006 and 2014 for cholecystectomy, pacemaker implantation, hip replacement, percutaneous coronary intervention (PCI), stroke, and acute myocardial infarction (AMI). We use risk-adjusted and unadjusted outcomes based on 16 indicators. Median outcome and outcome variation trends are examined via box plots, simple linear regressions and quintile differences. Outcome trends differ across treatment areas and indicators. We found positive quality trends for hip replacement surgery, stroke and AMI 30-day mortality, and negative quality trends for 90-day stroke and AMI readmissions and PCI inpatient mortality. Variation of risk-adjusted outcomes ranges by a factor of 3-12 between the 2nd and 5th quintile of hospitals, both at the national and regional level. Our results show that simply measuring and reporting hospital outcomes without clear incentives or regulation - "carrots and sticks" - to improve performance and to centralize care in high performing hospitals has not led to broad quality improvements. More substantial efforts must be undertaken to narrow the outcome spread between high- and low-quality hospitals.

Perceived barriers to effective implementation of public reporting of hospital performance data in Australia: a qualitative study

Background

Public reporting of government funded (public) hospital performance data was mandated in Australia in 2011. Studies suggest some benefit associated with such public reporting, but also considerable scope to improve reporting systems.

Methods

In 2015, a purposive sample of 41 expert informants were interviewed, representing consumer, provider and purchasers perspectives across Australia’s public and private health sectors, to ascertain expert opinion on the utility and impact of public reporting of health service performance. Qualitative data was thematically analysed with a focus on reporting perceived strengths and barriers to public reporting of hospital performance data (PR).

Results

Many more weaknesses and barriers to PR were identified than strengths. Barriers were: conceptual (unclear objective, audience and reporting framework); systems-level (including lack of consumer choice, lack of consumer and clinician involvement, jurisdictional barriers, lack of mandate for private sector reporting); technical and resource related (including data complexity, lack of data relevance consistency, rigour); and socio-cultural (including provider resistance to public reporting, poor consumer health literacy, lack of consumer empowerment).

Conclusions

Perceptions of the Australian experience of PR highlight important issues in its implementation that can provide lessons for Australia and elsewhere. A considerable weakness of PR in Australia is that the public are often not considered its major audience, resulting in information ineffectually framed to meet the objective of PR informing consumer decision-making about treatment options. Greater alignment is needed between the primary objective of PR, its audience and audience needs; more than one system of PR might be necessary to meet different audience needs and objectives. Further research is required to assess objectively the potency of the barriers to PR suggested by our panel of informants.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2336-7) contains supplementary material, which is available to authorized users.

Impact of State Reporting Laws on Central Line-Associated Bloodstream Infection Rates in U.S. Adult Intensive Care Units

OBJECTIVE

To examine the effect of mandated state health care-associated infection (HAI) reporting laws on central line-associated bloodstream infection (CLABSI) rates in adult intensive care units (ICUs).

DATA SOURCES

We analyzed 2006-2012 adult ICU CLABSI and hospital annual survey data from the National Healthcare Safety Network. The final analytic sample included 244 hospitals, 947 hospital years, 475 ICUs, 1,902 ICU years, and 16,996 ICU months.

STUDY DESIGN

We used a quasi-experimental study design to identify the effect of state mandatory reporting laws. Several secondary models were conducted to explore potential explanations for the plausible effects of HAI laws.

PRINCIPAL FINDINGS

Controlling for the overall time trend, ICUs in states with laws had lower CLABSI rates beginning approximately 6 months prior to the law's effective date (incidence rate ratio = 0.66; p < .001); this effect persisted for more than 6 1/2 years after the law's effective date. These findings were robust in secondary models and are likely to be attributed to changes in central line usage and/or resources dedicated to infection control.

CONCLUSIONS

Our results provide valuable evidence that state reporting requirements for HAIs improved care. Additional studies are needed to further explore why and how mandatory HAI reporting laws decreased CLABSI rates.

Increasing the Use of Comparative Quality Information in Maternity Care: Results From a Randomized Controlled Trial

This randomized controlled trial tested an intervention to increase uptake of hospital-level maternity care quality reports among 245 pregnant women in North Carolina (123 treatment; 122 control). The intervention included three enhancements to the quality report offered to the control: (a) biweekly text messages or e-mails directing women to the website, (b) videos and materials describing the relevance of quality measures to pregnant women's interests, and (c) tools to support discussions with clinicians. Compared with controls, intervention participants were significantly more likely to visit the website and report adopting behaviors to inform care, such as thinking through preferences, talking with their doctor, or creating a birth plan. Reports designed to put quality information into the larger context of what consumers want and need to know, along with targeted and timely communications, can increase consumer use of quality information and prompt them to talk with providers about care preferences and evidence-based practices.

Health care public reporting utilization - user clusters, web trails, and usage barriers on Germany's public reporting portal Weisse-Liste.de

BACKGROUND

Quality of care public reporting provides structural, process and outcome information to facilitate hospital choice and strengthen quality competition. Yet, evidence indicates that patients rarely use this information in their decision-making, due to limited awareness of the data and complex and conflicting information. While there is enthusiasm among policy makers for public reporting, clinicians and researchers doubt its overall impact. Almost no study has analyzed how users behave on public reporting portals, which information they seek out and when they abort their search.

METHODS

This study employs web-usage mining techniques on server log data of 17 million user actions from Germany's premier provider transparency portal Weisse-Liste.de (WL.de) between 2012 and 2015. Postal code and ICD search requests facilitate identification of geographical and treatment area usage patterns. User clustering helps to identify user types based on parameters like session length, referrer and page topic visited. First-level markov chains illustrate common click paths and premature exits.

RESULTS

In 2015, the WL.de Hospital Search portal had 2,750 daily users, with 25% mobile traffic, a bounce rate of 38% and 48% of users examining hospital quality information. From 2013 to 2015, user traffic grew at 38% annually. On average users spent 7 min on the portal, with 7.4 clicks and 54 s between clicks. Users request information for many oncologic and orthopedic conditions, for which no process or outcome quality indicators are available. Ten distinct user types, with particular usage patterns and interests, are identified. In particular, the different types of professional and non-professional users need to be addressed differently to avoid high premature exit rates at several key steps in the information search and view process. Of all users, 37% enter hospital information correctly upon entry, while 47% require support in their hospital search.

CONCLUSIONS

Several onsite and offsite improvement options are identified. Public reporting needs to be directed at the interests of its users, with more outcome quality information for oncology and orthopedics. Customized reporting can cater to the different needs and skill levels of professional and non-professional users. Search engine optimization and hospital quality advocacy can increase website traffic.

Yelp Reviews Of Hospital Care Can Supplement And Inform Traditional Surveys Of The Patient Experience Of Care

Little is known about how real-time online rating platforms such as Yelp may complement the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is the US standard for evaluating patients' experiences after hospitalization. We compared the content of Yelp narrative reviews of hospitals to the topics in the HCAHPS survey, called domains in HCAHPS terminology. While the domains included in Yelp reviews covered the majority of HCAHPS domains, Yelp reviews covered an additional twelve domains not found in HCAHPS. The majority of Yelp topics that most strongly correlate with positive or negative reviews are not measured or reported by HCAHPS. The large collection of patient- and caregiver-centered experiences found on Yelp can be analyzed with natural language processing methods, identifying for policy makers the measures of hospital quality that matter most to patients and caregivers. The Yelp measures and analysis can also provide actionable feedback for hospitals.

Factors That Matter to Low-Income and Racial/Ethnic Minority Mothers When Choosing a Pediatric Practice: a Mixed Methods Analysis

BACKGROUND

Pediatric practices' scores on healthcare quality measures are increasingly available to the public. However, patients from low-income and racial/ethnic minority populations rarely use these data. We sought to understand potential barriers to using quality data by assessing what factors mattered to women when choosing a pediatric practice.

METHODS

As part of a randomized trial to overcome barriers to using quality data, we recruited women from a prenatal clinic serving an underserved population. Women reported how much 12 factors mattered when they chose a pediatric practice (5-point Likert scale), what other factors mattered to them, and which factors mattered the most. We assessed whether factor importance varied with selected participant characteristics and qualitatively analyzed the "other" factors named.

RESULTS

Participants' (n = 367) median age was 23 years, and they were largely Hispanic (60.4%), white (21.2%), or black (16.9%). Insurance acceptance "mattered a lot" to the highest percentage of women (93.2%), while online information about what other parents think of a practice "mattered a lot" to the fewest (7.4%). Major themes from our qualitative analysis of "other" factors that mattered included physicians' interpersonal skills and pediatrician-specific traits. Factors related to access "mattered the most" to the majority of women.

CONCLUSIONS

Pediatrician characteristics and factors related to access to care may be more important to low-income and racial/ethnic minority women than more commonly reported quality metrics. Aligning both the content and delivery of publicly reported quality data with women's interests may increase use of pediatric quality data.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT01784575.

How rural and urban patients in Australia with colorectal or breast cancer experience choice of treatment provider: A qualitative study

Modern healthcare systems promote patient choice of cancer treatment provider, but little is known about how place of residence influences decision-making. This research explored how rural and urban patients with breast or colorectal cancer experience choice of cancer treatment provider in Victoria, Australia. Realist thematic analysis of 43 semi-structured telephone interviews identified little active participation in decision-making regardless of area of residence or cancer diagnosis. Perceptions of choice were impacted by urgency for treatment, insurance status and access to providers, a key issue for rural patients. All patients wanted high quality care, but needed to trust health professional's recommendations. Rural patients experienced more complex decision-making, balancing a range of social factors with perceptions about quality of accessible care. Further research into variation in quality of care and complex cancer pathways for rural and urban cancer patients is warranted to inform choices and enhance patient-centred care.

Information and choice of residential care provider for older people: a comparative study in England, the Netherlands and Spain

This study compared how older people use quality information to choose residential care providers in England, the Netherlands and Spain (Catalonia). The availability of information varies between each country, from detailed inspection and survey information in the Netherlands, through to a lack of publicly available information in Catalonia. We used semi-structured interviews and group workshops with older people, families and professionals to compare experiences of the decision-making process and quality information, and also to explore what quality information might be used in the future. We found that most aspects of the decision-making experience and preferences for future indicators were similar across the three countries. The use of quality information was minimal across all three, even in England and the Netherlands where information was widely available. Differences arose mainly from factors with the supply of care. Older people were most interested in the subjective experiences of other residents and relatives, rather than ‘hard’ objective indicators of aspects such as clinical care. We find that the amount of publicly available quality information does not in itself influence the decisions or the decision-making processes of older people and their carers. To improve the quality of decisions, more effort needs to be taken to increase awareness and to communicate quality in more accessible ways, including significant support from professionals and better design of quality information.

Reporting individual surgeon outcomes does not lead to risk aversion in abdominal aortic aneurysm surgery

INTRODUCTION Reporting surgeons' outcomes has recently been introduced in the UK. This has the potential to result in surgeons becoming risk averse. The aim of this study was to investigate whether reporting outcomes for abdominal aortic aneurysm (AAA) surgery impacts on the number and risk profile (level of fitness) of patients offered elective treatment. METHODS Publically available National Vascular Registry data were used to compare the number of AAAs treated in those centres across the UK that reported outcomes for the periods 2008-2012, 2009-2013 and 2010-2014. Furthermore, the number and characteristics of patients referred for consideration of elective AAA repair at a single tertiary unit were analysed yearly between 2010 and 2014. Clinic, casualty and theatre event codes were searched to obtain all AAAs treated. The results of cardiopulmonary exercise testing (CPET) were assessed. RESULTS For the 85 centres that reported outcomes in all three five-year periods, the median number of AAAs treated per unit increased between the periods 2008-2012 and 2010-2014 from 192 to 214 per year (p=0.006). In the single centre cohort study, the proportion of patients offered elective AAA repair increased from 74% in 2009-2010 to 81% in 2013-2014, with a maximum of 84% in 2012-2013. The age, aneurysm size and CPET results (anaerobic threshold levels) for those eventually offered elective treatment did not differ significantly between 2010 and 2014. CONCLUSIONS The results do not support the assumption that reporting individual surgeon outcomes is associated with a risk averse strategy regarding patient selection in aneurysm surgery at present.

Health system frameworks and performance indicators in eight countries: A comparative international analysis

OBJECTIVES

Performance indicators are a popular mechanism for measuring the quality of healthcare to facilitate both quality improvement and systems management. Few studies make comparative assessments of different countries' performance indicator frameworks. This study identifies and compares frameworks and performance indicators used in selected Organisation for Economic Co-operation and Development health systems to measure and report on the performance of healthcare organisations and local health systems. Countries involved are Australia, Canada, Denmark, England, the Netherlands, New Zealand, Scotland and the United States.

METHODS

Identification of comparable international indicators and analyses of their characteristics and of their broader national frameworks and contexts were undertaken. Two dimensions of indicators - that they are nationally consistent (used across the country rather than just regionally) and locally relevant (measured and reported publicly at a local level, for example, a health service) - were deemed important.

RESULTS

The most commonly used domains in performance frameworks were safety, effectiveness and access. The search found 401 indicators that fulfilled the 'nationally consistent and locally relevant' criteria. Of these, 45 indicators are reported in more than one country. Cardiovascular, surgery and mental health were the most frequently reported disease groups.

CONCLUSION

These comparative data inform researchers and policymakers internationally when designing health performance frameworks and indicator sets.

Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care

Background

The feedback of patient-reported outcome measures (PROMs) data is intended to support the care of individual patients and to act as a quality improvement (QI) strategy.

Objectives

To (1) identify the ideas and assumptions underlying how individual and aggregated PROMs data are intended to improve patient care, and (2) review the evidence to examine the circumstances in which and processes through which PROMs feedback improves patient care.

Design

Two separate but related realist syntheses: (1) feedback of aggregate PROMs and performance data to improve patient care, and (2) feedback of individual PROMs data to improve patient care.

Interventions

Aggregate – feedback and public reporting of PROMs, patient experience data and performance data to hospital providers and primary care organisations. Individual – feedback of PROMs in oncology, palliative care and the care of people with mental health problems in primary and secondary care settings.

Main outcome measures

Aggregate – providers’ responses, attitudes and experiences of using PROMs and performance data to improve patient care. Individual – providers’ and patients’ experiences of using PROMs data to raise issues with clinicians, change clinicians’ communication practices, change patient management and improve patient well-being.

Data sources

Searches of electronic databases and forwards and backwards citation tracking.

Review methods

Realist synthesis to identify, test and refine programme theories about when, how and why PROMs feedback leads to improvements in patient care.

Results

Providers were more likely to take steps to improve patient care in response to the feedback and public reporting of aggregate PROMs and performance data if they perceived that these data were credible, were aimed at improving patient care, and were timely and provided a clear indication of the source of the problem. However, implementing substantial and sustainable improvement to patient care required system-wide approaches. In the care of individual patients, PROMs function more as a tool to support patients in raising issues with clinicians than they do in substantially changing clinicians’ communication practices with patients. Patients valued both standardised and individualised PROMs as a tool to raise issues, but thought is required as to which patients may benefit and which may not. In settings such as palliative care and psychotherapy, clinicians viewed individualised PROMs as useful to build rapport and support the therapeutic process. PROMs feedback did not substantially shift clinicians’ communication practices or focus discussion on psychosocial issues; this required a shift in clinicians’ perceptions of their remit.

Strengths and limitations

There was a paucity of research examining the feedback of aggregate PROMs data to providers, and we drew on evidence from interventions with similar programme theories (other forms of performance data) to test our theories.

Conclusions

PROMs data act as ‘tin openers’ rather than ‘dials’. Providers need more support and guidance on how to collect their own internal data, how to rule out alternative explanations for their outlier status and how to explore the possible causes of their outlier status. There is also tension between PROMs as a QI strategy versus their use in the care of individual patients; PROMs that clinicians find useful in assessing patients, such as individualised measures, are not useful as indicators of service quality.

Future work

Future research should (1) explore how differently performing providers have responded to aggregate PROMs feedback, and how organisations have collected PROMs data both for individual patient care and to improve service quality; and (2) explore whether or not and how incorporating PROMs into patients’ electronic records allows multiple different clinicians to receive PROMs feedback, discuss it with patients and act on the data to improve patient care.

Study registration

This study is registered as PROSPERO CRD42013005938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Public reporting as a prescriptions quality improvement measure in primary care settings in China: variations in effects associated with diagnoses

The overprovision and irrational use of antibiotics and injections are a major public health concern. Public reporting has been adopted as a strategy to encourage good prescribing practices. This study evaluated the effects of public reporting on antibiotic and injection prescriptions in urban and rural primary care settings in Hubei province, China. A randomized control trial was conducted, with 10 primary care institutions being subject to public reporting and another 10 serving as controls. Prescription indicators were publicly reported monthly over a one-year period. Prescriptions for bronchitis, gastritis and hypertension before and after the intervention were collected. Difference-in-difference tests were performed to estimate the effect size of the intervention on five prescription indicators: percentage of prescriptions containing antibiotics; percentage of prescriptions containing two or more antibiotics; percentage of prescriptions containing injections; percentage of prescriptions containing antibiotic injections; and average prescription cost. Public reporting had varied effects on prescriptions for different diagnoses. It reduced antibiotic prescribing for gastritis. Prescriptions containing injections, especially antibiotic injections, also declined, but only for gastritis. A reduction of prescription costs was noted for bronchitis and gastritis. Public reporting has the potential to encourage good prescribing practices. Its effects vary with different disease conditions.

Patients' Need for Tailored Comparative Health Care Information: A Qualitative Study on Choosing a Hospital

BACKGROUND

The Internet is increasingly being used to provide patients with information about the quality of care of different health care providers. Although online comparative health care information is widely available internationally, and patients have been shown to be interested in this information, its effect on patients' decision making is still limited.

OBJECTIVE

This study aimed to explore patients' preferences regarding information presentation and their values concerning tailored comparative health care information. Meeting patients' information presentation needs might increase the perceived relevance and use of the information.

METHODS

A total of 38 people participated in 4 focus groups. Comparative health care information about hip and knee replacement surgery was used as a case example. One part of the interview focused on patients' information presentation preferences, whereas the other part focused on patients' values of tailored information (ie, showing reviews of patients with comparable demographics). The qualitative data were transcribed verbatim and analyzed using the constant comparative method.

RESULTS

The following themes were deduced from the transcripts: number of health care providers to be presented, order in which providers are presented, relevancy of tailoring patient reviews, and concerns about tailoring. Participants' preferences differed concerning how many and in which order health care providers must be presented. Most participants had no interest in patient reviews that were shown for specific subgroups based on age, gender, or ethnicity. Concerns of tailoring were related to the representativeness of results and the complexity of information. A need for information about the medical specialist when choosing a hospital was stressed by several participants.

CONCLUSIONS

The preferences for how comparative health care information should be presented differ between people. "Information on demand" and information about the medical specialist might be promising ways to increase the relevancy and use of online comparative health care information. Future research should focus on how different groups of people use comparative health care information for different health care choices in real life.

Patient Navigators and Parent Use of Quality Data: A Randomized Trial

BACKGROUND

Consumers rarely use publicly reported health care quality data. Despite known barriers to use, few studies have explored the effectiveness of strategies to overcome barriers in vulnerable populations.

METHODS

This randomized controlled trial tested the impact of a patient navigator intervention to increase consumer use of publicly reported quality data. Patients attending an urban prenatal clinic serving a vulnerable population enrolled between May 2013 and January 2015. The intervention consisted of 2 in-person sessions in which women learned about quality performance and viewed scores for local practices on the Massachusetts Health Quality Partners Web site. Women in both the intervention and control arms received a pamphlet about health care quality. Primary study outcomes were mean clinical quality and patient experience scores of the practices women selected (range 1-4 stars).

RESULTS

Nearly all (726/746; 97.3%) women completed the study, 59.7% were Hispanic, and 65.1% had a high school education or less. In both unadjusted and adjusted models, women in the intervention group chose practices with modestly higher mean clinical quality (3.2 vs 3.0 stars; P = .001) and patient experience (3.0 vs 2.9 stars; P = .05) scores. When asked to rate what factors mattered the most in their decision, few cited quality scores.

CONCLUSIONS

An intervention to reduce barriers to using publicly reported health care quality data had a modest effect on patient choice. These findings suggest that factors other than performance on common publicly reported quality metrics have a stronger influence on which pediatric practices women choose.

A statewide controlled trial intervention to reduce use of unproven or ineffective breast cancer care

BACKGROUND

Challenged by public opinion, peers and the Congressional Budget Office, medical specialty societies have begun to develop "Top Five" lists of expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The extent to which these lists have influenced the behavior of physicians or patients, however, remains unknown.

METHODS

We partner with a statewide consortium of health systems to examine the effectiveness of two interventions: (i) "basic" public reporting and (ii) an "enhanced" intervention, augmenting public reporting with a smart phone-based application that gives providers just-in-time information, decision-making tools, and personalized patient education materials to support reductions in the use of eight breast cancer interventions targeted by Choosing Wisely® or oncology society guidelines. Our aims are: (1) to examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states; (2) to examine the effectiveness of the enhanced intervention relative to the basic intervention; and (3) to simulate cost savings forthcoming from nationwide implementation of both interventions.

DISCUSSION

The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system for influencing provider behavior that may be easily exportable to other states, and potentially also to large healthcare systems. Findings will be further relevant to the ACO environment, which is expected to provide financial disincentives for ineffective or unproven care.

TRIAL REGISTRATION

ClinicalTrials.gov number pending.

Public Reporting of Mortality Rates for Hospitalized Medicare Patients and Trends in Mortality for Reported Conditions

BACKGROUND

Public reporting is seen as a powerful quality improvement tool, but data to support its efficacy are limited. The Centers for Medicare & Medicaid Services' Hospital Compare program initially reported process metrics only but started reporting mortality rates for acute myocardial infarction, heart failure, and pneumonia in 2008.

OBJECTIVE

To determine whether public reporting of mortality rates was associated with lower mortality rates for these conditions among Medicare beneficiaries.

DESIGN

For 2005 to 2007, process-only reporting was considered; for 2008 to 2012, process and mortality reporting was considered. Changes in mortality trends before and during reporting periods were estimated by using patient-level hierarchical modeling. Nonreported medical conditions were used as a secular control.

SETTING

U.S. acute care hospitals.

PARTICIPANTS

20 707 266 fee-for-service Medicare beneficiaries hospitalized from January 2005 through November 2012.

MEASUREMENTS

30-day risk-adjusted mortality rates.

RESULTS

Mortality rates for the 3 publicly reported conditions were changing at an absolute rate of -0.23% per quarter during process-only reporting, but this change slowed to a rate of -0.09% per quarter during process and mortality reporting (change, 0.13% per quarter; 95% CI, 0.12% to 0.14%). Mortality for nonreported conditions was changing at -0.17% per quarter during process-only reporting and slowed slightly to -0.11% per quarter during process and mortality reporting (change, 0.06% per quarter; CI, 0.05% to 0.07%).

LIMITATION

Administrative data may have limited ability to account for changes in patient complexity over time.

CONCLUSION

Changes in mortality trends suggest that reporting in Hospital Compare was associated with a slowing, rather than an improvement, in the ongoing decline in mortality among Medicare patients.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

Does public reporting influence antibiotic and injection prescribing to all patients? A cluster-randomized matched-pair trial in china

The inappropriate use and overuse of antibiotics and injections are serious threats to global population, and the public reporting of health care performance (PRHCP) has been an important instrument for improving the quality of care. However, existing evidence shows a mixed effect of PRHCP. This study is to explore the potential effectiveness of PRHCP that contributes to the convincing evidence of health policy and reform.This study was undertaken in Qian Jiang City, applying a matched-pair cluster-randomized trial. Twenty primary care institutions were treated as clusters and were matched into 10 pairs. Clusters in each pair were randomly assigned into a control or an intervention group. Physicians' prescribing information was publicly reported to patients and physicians monthly in the intervention group from October 2013. A total of 748,632 outpatient prescriptions were included for difference-in-difference (DID) regression model and subgroups (SGs) analysis.Overall, PRHCP intervention led to a slight reduction in the use of combined antibiotics (odds ratio [OR] = 0.870, P < 0.001) and slowed the average expenditure increase of patients (coefficient = -0.051, P < 0.001). SG analysis showed the effect of PRHCP varied among patients with different characteristics. PRHCP decreased the probability of prescriptions requiring antibiotics, combined antibiotics, and injections of patients aged 18 to 64 years old (OR < 1), and all results were statistically significant. By contrast, the results of elderly and minor patients with health insurance showed that PRHCP increased their probability of prescriptions requiring antibiotics and injections. PRHCP slowed the increase of average expenditure of most SGs.PRHCP intervention can influence the prescribing pattern of physicians. Patient factors such as age and health insurance influence the effect of PRHCP intervention, which imply that PRHCP should be designed for different patients. Patient education, aiming at radically changing attitudes toward antibiotics and injections, should be taken to promote the effectiveness of public reporting in China.

Using the Consumer Experience with Pharmacy Services Survey as a quality metric for ambulatory care pharmacies: older adults' perspectives

OBJECTIVES

To describe older adults' perceptions of evaluating and comparing pharmacies based on the Consumer Experience with Pharmacy Services Survey (CEPSS), describe older adults' perceived importance of the CEPSS and its specific domains, and explore older adults' perceptions of the influence of specific CEPSS domains in choosing/switching pharmacies.

DESIGN

Focus group methodology was combined with the administration of a questionnaire. The focus groups explored participants' perceived importance of the CEPSS and their perception of using the CEPSS to choose and/or switch pharmacies. Then, using the questionnaire, participants rated their perceived importance of each CEPSS domain in evaluating a pharmacy, and the likelihood of using CEPSS to switch pharmacies if their current pharmacy had low ratings. Descriptive and thematic analyses were done.

SETTING

6 semistructured focus groups were conducted in a private meeting room in a Mid-Western state in the USA.

PARTICIPANTS

60 English-speaking adults who were at least 65 years, and had filled a prescription at a retail pharmacy within 90 days.

RESULTS

During the focus groups, the older adults perceived the CEPSS to have advantages and disadvantages in evaluating and comparing pharmacies. Older adults thought the CEPSS was important in choosing the best pharmacies and avoiding the worst pharmacies. The perceived influence of the CEPSS in switching pharmacies varied depending on the older adult's personal experience or trust of other consumers' experience. Questionnaire results showed that participants perceived health/medication-focused communication as very important or extremely important (n=47, 82.5%) in evaluating pharmacies and would be extremely likely (n=21, 36.8%) to switch pharmacies if their pharmacy had low ratings in this domain.

CONCLUSIONS

The older adults in this study are interested in using patient experiences as a quality metric for avoiding the worst pharmacies. Pharmacists' communication about health and medicines is perceived important and likely to influence older adults' pharmacy selection.

Reporting and use of the OECD Health Care Quality Indicators at national and regional level in 15 countries

QUALITY PROBLEM OR ISSUE

OECD member states are involved since 2003 in a project coordinated by the OECD on Health Care Quality Indicators (HCQI). All OECD countries are biennially requested by the OECD to deliver national data on the quality indicators for international benchmarking purposes.

INITIAL ASSESSMENT

Currently, there is no knowledge whether the OECD HCQI information is used by the countries themselves for healthcare system accountability and improvement purposes.

CHOICE OF SOLUTION

The objective of the study is to explore the reporting and use of OECD HCQI in OECD member-states.

IMPLEMENTATION

Data were collected through a questionnaire sent to all OECD member-states containing factual questions on the reporting on all OECD HCQ-indicators. Responses were received between June and December 2014. In this timeframe, two reminders were sent to the participants. The work progress was presented during HCQI Meetings in November 2014 and May 2015.

EVALUATION

Fifteen countries reported to have a total of 163 reports in which one or more HCQIs were reported. One hundred and sixteen were national and 47 were regional reports. Forty-nine reports had a general system focus, 80 were disease specific, 10 referred to a specific type of care setting, 22 were thematic and 2 were a combination of two (disease specific for a particular type of care and thematic for a specific type of care). Most reports were from Canada: 49. All 15 countries use one or more OECD indicators.

LESSONS LEARNED

The OECD quality indicators have acquired a clear place in national and regional monitoring activities. Some indicators are reported more often than others. These differences partly reflect differences between healthcare systems. Whereas some indicators have become very common, such as cancer care indicators, others, such as mental healthcare and patient experience indicators are relatively new and require some more time to be adopted more widely.

A Cluster-Randomized Trial of Two Strategies to Improve Antibiotic Use for Patients with a Complicated Urinary Tract Infection

BACKGROUND

Up to 50% of hospital antibiotic use is inappropriate and therefore improvement strategies are urgently needed. We compared the effectiveness of two strategies to improve the quality of antibiotic use in patients with a complicated urinary tract infection (UTI).

METHODS

In a multicentre, cluster-randomized trial 19 Dutch hospitals (departments Internal Medicine and Urology) were allocated to either a multi-faceted strategy including feedback, educational sessions, reminders and additional/optional improvement actions, or a competitive feedback strategy, i.e. providing professionals with non-anonymous comparative feedback on the department's appropriateness of antibiotic use. Retrospective baseline- and post-intervention measurements were performed in 2009 and 2012 in 50 patients per department, resulting in 1,964 and 2,027 patients respectively. Principal outcome measures were nine validated guideline-based quality indicators (QIs) that define appropriate antibiotic use in patients with a complicated UTI, and a QI sumscore that summarizes for each patient the appropriateness of antibiotic use.

RESULTS

Performance scores on several individual QIs showed improvement from baseline to post-intervention measurements, but no significant differences were found between both strategies. The mean patient's QI sum score improved significantly in both strategy groups (multi-faceted: 61.7% to 65.0%, P = 0.04 and competitive feedback: 62.8% to 66.7%, P = 0.01). Compliance with the strategies was suboptimal, but better compliance was associated with more improvement.

CONCLUSION

The effectiveness of both strategies was comparable and better compliance with the strategies was associated with more improvement. To increase effectiveness, improvement activities should be rigorously applied, preferably by a locally initiated multidisciplinary team.

TRIAL REGISTRATION

Nederlands Trial Register 1742.

Using Patient-Reported Information to Improve Clinical Practice

OBJECTIVE

To assess what is known about the relationship between patient experience measures and incentives designed to improve care, and to identify how public policy and medical practices can promote patient-valued outcomes in health systems with strong financial incentives.

DATA SOURCES/STUDY SETTING

Existing literature (gray and peer-reviewed) on measuring patient experience and patient-reported outcomes, identified from Medline and Cochrane databases; evaluations of pay-for-performance programs in the United States, Europe, and the Commonwealth countries.

STUDY DESIGN/DATA COLLECTION

We analyzed (1) studies of pay-for-performance, to identify those including metrics for patient experience, and (2) studies of patient experience and of patient-reported outcomes to identify evidence of influence on clinical practice, whether through public reporting or private reporting to clinicians.

PRINCIPAL FINDINGS

First, we identify four forms of "patient-reported information" (PRI), each with distinctive roles shaping clinical practice: (1) patient-reported outcomes measuring self-assessed physical and mental well-being, (2) surveys of patient experience with clinicians and staff, (3) narrative accounts describing encounters with clinicians in patients' own words, and (4) complaints/grievances signaling patients' distress when treatment or outcomes fall short of expectations. Because these forms vary in crucial ways, each must be distinctively measured, deployed, and linked with financial incentives. Second, although the literature linking incentives to patients experience is limited, implementing pay-for-performance systems appears to threaten certain patient-valued aspects of health care. But incentives can be made compatible with the outcomes patients value if: (a) a sufficient portion of incentives is tied to patient-reported outcomes and experiences, (b) incentivized forms of PRI are complemented by other forms of patient feedback, and (c) health care organizations assist clinicians to interpret and respond to PRI. Finally, we identify roles for the public and private sectors in financing PRI and orchestrating an appropriate balance among its four forms.

CONCLUSIONS

Unless public policies are attentive to patients' perspectives, stronger financial incentives for clinicians can threaten aspects of care that patients most value. Certain policy parameters are already clear, but additional research is required to clarify how best to collect patient narratives in varied settings, how to report narratives to consumers in conjunction with quantified metrics, and how to promote a "culture of learning" at the practice level that incorporates patient feedback.