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Primary study

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Information and consumer choice: the value of publicized health plan ratings.

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Authors Jin GZ , Sorensen AT
Journal Journal of health economics
Year 2006
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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We use data on the enrollment decisions of federal annuitants to estimate the influence of publicized ratings on health plan choice. We focus on the impact of ratings disseminated by the National Committee for Quality Assurance (NCQA), and use our estimates to calculate the value of the information. Our approach exploits a novel feature of the data-the availability of non-public plan ratings-to correct for a source of bias that is inherent in studies of consumer responsiveness to information on product quality: since publicized ratings are correlated with other quality signals known to consumers (but unobserved by researchers), the estimated influence of ratings is likely to be overstated. We control for this bias by comparing the estimated impact of publicized ratings to the estimated impact of ratings that were never disclosed. The results indicate that NCQA's plan ratings had a meaningful influence on individuals' choices, particularly for individuals choosing a plan for the first time. Although we estimate that a very small fraction of individual decisions were materially affected by the information, for those that were affected the implied utility gains are substantial.

Primary study

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The predictive accuracy of the New York State coronary artery bypass surgery report-card system.

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Authors Jha AK , Epstein AM
Journal Health affairs (Project Hope)
Year 2006
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This article is included in 4 Systematic reviews Systematic reviews (4 references)

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We examined the impact of New York State's public reporting system for coronary artery bypass surgery fifteen years after its launch. We found that users who picked a top-performing hospital or surgeon from the latest available report had approximately half the chance of dying as did those who picked a hospital or surgeon from the bottom quartile. Nevertheless, performance was not associated with a subsequent change in market share. Surgeons with the highest mortality rates were much more likely than other surgeons to retire or leave practice after the release of each report card.

Primary study

Unclassified

Quality report cards, selection of cardiac surgeons, and racial disparities: a study of the publication of the New York State Cardiac Surgery Reports.

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Journal Inquiry : a journal of medical care organization, provision and financing
Year 2005
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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Quality report cards have become common in many health care markets. This study evaluates their effectiveness by examining the impact of the New York State (NYS) Cardiac Surgery Reports on selection of cardiac surgeons. The analyses compares selection of surgeons in 1991 (pre-report publication) and 1992 (post-report publication). We find that the information about a surgeon's quality published in the reports influences selection directly and diminishes the importance of surgeon experience and price as signals for quality. Furthermore, selection of surgeons for black patients is as sensitive to the published information as is the selection for white patients.

Primary study

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Impact of star performance ratings in English acute hospital trusts.

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Authors Mannion R , Davies H , Marshall M
Journal Journal of health services research & policy
Year 2005
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This article is included in 3 Systematic reviews Systematic reviews (3 references)

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OBJECTIVE: To explore some of the impacts of star performance ratings in acute hospital trusts in England. METHODS: A multiple case study design was used which incorporated purposeful sampling of 'low' and 'high' performing trusts using the star rating system. In each case study site, data collection comprised semi-structured interviews and documentary analysis. Between eight and 12 senior managers and senior clinicians were interviewed in each organisation. RESULTS: There was a general view that the star ratings as presently constituted did not represent a rounded or balanced scorecard of their own organisation's performance and a widespread belief that the information used to calculate the ratings was often incomplete and inaccurate. The star ratings were viewed by some managers as useful, in that they gave added weight to their trust's modernisation agenda. In addition to driving beneficial change, the ratings were also sometimes reported to have inadvertently induced a range of unintended and dysfunctional consequences, including tunnel vision and a distortion of clinical priorities, bullying and intimidation, erosion of public trust and reduced staff morale, and ghettoisation. CONCLUSIONS: Set in the context of an international body of research, this study highlights some important gaps in knowledge and failings in current policy and practice. In particular, the many dysfunctional consequences of publishing star ratings indicate a need for a re-examination of performance management policies.

Primary study

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Public reporting and case selection for percutaneous coronary interventions: an analysis from two large multicenter percutaneous coronary intervention databases.

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Journal Journal of the American College of Cardiology
Year 2005
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This article is included in 4 Systematic reviews Systematic reviews (4 references)

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OBJECTIVES: The purpose of this research was to determine the potential effect of public reporting on case selection for percutaneous coronary intervention (PCI). BACKGROUND: Previous studies have suggested that public reporting of coronary artery bypass graft surgery (CABG) mortality might result in case selection bias and in denial of care to or out migration of high-risk patients. The potential effect of public reporting on case selection for PCI is unknown. METHODS: We compared demographics, indications, and outcomes of 11,374 patients included in a multicenter (eight hospitals) PCI database in Michigan where no public reporting is present, with 69,048 patients in a statewide (34 hospitals) PCI database in New York, where public reporting is present. The primary end point was in-hospital mortality. RESULTS: Patients in Michigan more frequently underwent PCI for acute myocardial infarction (14.4% vs. 8.7%, p < 0.0001) and cardiogenic shock (2.56% vs. 0.38%, p < 0.0001) than those in New York. The Michigan cohort also had a higher prevalence of congestive heart failure and extracardiac vascular disease. The unadjusted in-hospital mortality rate was significantly lower in New York than in Michigan (0.83% vs. 1.54%, p < 0.0001; odds ratio [OR] 0.54, 95% confidence interval [CI] 0.45 to 0.63). However, after adjustment for comorbidities, there was no significant difference in mortality between the two groups (adjusted OR 1.05, 95% CI 0.84 to 1.31, p = 0.70, c-statistic 0.88). CONCLUSIONS: There are significant differences in case mix between patients undergoing PCI in Michigan and New York that result in marked differences in unadjusted mortality rates. A propensity in New York toward not intervening on higher-risk patients because of fear of public reporting of high mortality rates is a possible explanation for these differences.

Primary study

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Hospital performance reports: impact on quality, market share, and reputation.

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Authors Hibbard JH , Stockard J , Tusler M
Journal Health affairs (Project Hope)
Year 2005
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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This study builds on earlier work by assessing the long-term impact of a public hospital performance report on both consumers and hospitals. In doing so, we shed light on the relative importance of alternative assumptions about what stimulates quality improvements. The findings indicate that making performance data public results in improvements in the clinical area reported upon. An earlier investigation indicated that hospitals included in the public report believed that the report would affect their public image. Indeed, consumer surveys suggest that inclusion did affect hospitals' reputations.

Primary study

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Racial profiling: the unintended consequences of coronary artery bypass graft report cards.

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Authors Werner RM , Asch DA , Polsky D
Journal Circulation
Year 2005
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This article is included in 3 Systematic reviews Systematic reviews (3 references)

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BACKGROUND: Although public release of quality information through report cards is intended to improve health care, there may be unintended consequences of report cards, such as physicians avoiding high-risk patients to improve their ratings. If physicians believe that racial and ethnic minorities are at higher risk for poor outcomes, report cards could worsen existing racial and ethnic disparities in health care. METHODS AND RESULTS: To investigate the impact of New York's CABG report card on racial and ethnic disparities in cardiac care, we estimated differences in the use of CABG, PTCA, and cardiac catheterization between white versus black and Hispanic patients hospitalized for acute myocardial infarction in New York before and after New York's first CABG report card was released, adjusting for patient and hospital characteristics and national changes in racial and ethnic disparities in cardiac care. The racial and ethnic disparity in CABG use significantly increased in New York immediately after New York's CABG report card was released, whereas disparities did not change significantly in the comparison states. There was no differential change in racial and ethnic disparities between New York and the comparison states in the use of cardiac catheterization or PTCA after the CABG report card was released. Over time, this increase in racial and ethnic disparities decreased to levels similar to those before the release of report cards. CONCLUSIONS: The release of CABG report cards in New York was associated with a widening of the disparity in CABG use between white versus black and Hispanic patients.

Primary study

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The influence of public reporting of outcome data on medical decision making by physicians.

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Authors Narins CR , Dozier AM , Ling FS , Zareba W
Journal Archives of internal medicine
Year 2005
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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BACKGROUND: Public disclosure of physician-specific performance data is becoming increasingly common. However, the influence that public reporting of outcome data has on the delivery of care by physicians who are being assessed is not well understood. METHODS: Since 1994, the New York State Department of Health has collected and periodically published observed and risk-adjusted patient mortality rates for all interventional cardiologists practicing coronary angioplasty in the state. To assess the influence that these reports exert on the physicians being monitored, a questionnaire was administered in an anonymous manner to all interventional cardiologists included in the most recent report. RESULTS: The vast majority (79%) of interventional cardiologists agreed or strongly agreed that the publication of mortality statistics has, in certain instances, influenced their decision regarding whether to perform angioplasty on individual patients. Physicians expressed an increased reluctance to intervene in critically ill patients with high expected mortality rates. Among the respondents, 83% agreed or strongly agreed that patients who might benefit from angioplasty may not receive the procedure as a result of public reporting of physician-specific patients' mortality rates. Additionally, 85% believed that the risk-adjustment model used in the Percutaneous Coronary Interventions (PCI) in New York State 1998-2000 report is not sufficient to avoid punishing physicians who perform higher-risk interventions. CONCLUSIONS: Public reporting of physician-specific outcome data may influence physicians to withhold procedures from patients at higher risk, even when physicians believe that the procedure might be beneficial. This phenomenon should be recognized in the design and administration of physician performance profiles.

Primary study

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Do well-publicized risk-adjusted outcomes reports affect hospital volume?

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Authors Romano PS , Zhou H
Journal Medical care
Year 2004
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This article is included in 3 Systematic reviews Systematic reviews (3 references)

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BACKGROUND: Report cards on hospital performance are common but have uncertain impact. OBJECTIVES: The objective of this study was to determine whether hospitals recognized as performance outliers experience volume changes after publication of a report card. Secondary objectives were to test whether favorable outliers attract more patients with related conditions, or from outside their catchment areas; and whether disadvantaged groups are less responsive to report cards. STUDY DESIGN: We used a time-series analysis using linear and autoregressive models. SUBJECTS: We studied patients admitted to nonfederal hospitals designated as outliers in reports on coronary bypass surgery (CABG) mortality in New York, acute myocardial infarction (AMI) mortality in California, and postdiskectomy complications in California. MEASURES: We studied observed versus expected hospital volume for topic and related conditions and procedures, by month/quarter after a report card, with and without stratification by age, race/ethnicity, insurance, and catchment area. Potential confounders included statewide prevalence, prereport hospital volume and market share, and unrelated volume. RESULTS: In California, low-mortality and high-mortality outliers did not experience changes in AMI volume after adjusting for autocorrelation. Low-complication outliers for lumbar diskectomy experienced slightly increased volume in autoregressive models. No other cohorts demonstrated consistent trends. In New York, low-mortality outliers experienced significantly increased CABG volume in the first month after publication, whereas high-mortality outliers experienced decreased volume in the second month. The strongest effects were among white patients and those with HMO coverage in California, and among white or other patients and those with Medicare in New York. CONCLUSIONS: Volume effects were modest, transient, and largely limited to white Medicare patients in New York.

Primary study

Unclassified

The effect of publicly reporting hospital performance on market share and risk-adjusted mortality at high-mortality hospitals.

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Journal Medical care
Year 2003
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This article is included in 3 Systematic reviews Systematic reviews (3 references)

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BACKGROUND: It is unclear whether publicly reporting hospitals' risk-adjusted mortality affects market share and mortality at outlier hospitals. OBJECTIVES: To examine hospitals' market share and risk-adjusted mortality from 1991 to 1997 at hospitals participating in Cleveland Health Quality Choice (CHQC). RESEARCH DESIGN: Time series. SUBJECTS: Changes in market share were examined for all patients hospitalized with acute myocardial infarction, heart failure, gastrointestinal hemorrhage, obstructive pulmonary disease, pneumonia, or stroke at all 30 nonfederal hospitals in Northeast Ohio. Patients insured by Medicare were used to examine changes in mortality. MEASURES: Trends in market share (proportion of patients with the target conditions discharged from a given hospital) and risk-adjusted 30-day mortality. RESULTS: CHQC identified several hospitals with consistently higher than expected mortality. The five hospitals with the highest mortality tended to lose market share (mean change -0.6%, 95% CI -1.9-0.6), but this was not significant. The only outlier hospital with a large decline in market share had declining volume for 2 years before being declared an outlier. Risk-adjusted mortality declined only slightly at hospitals classified by us as "below average" (-0.8%; 95% CI, 2.9-1.8%) or "worst" (-0.4%; 95% CI -2.3-1.7). However, risk-adjusted mortality at one hospital changed from consistently above expected to consistently below expected shortly after first being declared an outlier. CONCLUSION: Despite CHQC's strengths, identifying hospitals with higher than expected mortality did not adversely affect their market share or, with one exception, lead to improved outcomes. This failure may have resulted from consumer disinterest or difficulty interpreting CHQC reports, unwillingness of businesses to create incentives targeted to hospitals' performance, and hospitals' inability to develop effective quality improvement programs.