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The Role of Hospital Transparency

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The Problem

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Transparency – the public reporting of cost and outcomes information – will lead to improved value in health care. The “T word” is now political Mom and apple pie.

Consumers of healthcare, made price sensitive by appropriate product design and informed by detailed outcomes and price information, will shop for value and bring market forces to bear on both cost and quality.

Premise

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Utilization of High Cost Imaging Tests at PCHI

85

55

15

98

65

21

113

75

27

134

82

33

-

20

40

60

80

100

120

140

160

CT MRI Nuc-Card

Pro

ce

du

res

/10

00

2000

2001

2002

2003

The Provider’s dilemma

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Four issues with transparency

• Data limitations -- relates to data sources and appropriate use of statistics

• Some tasks are harder to accomplish than others, some patients are sicker than others -- risk adjustment

• The realities of media/consumer understanding

• Unintended consequences of public reporting

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JOHNS HOPKINS HOSPITAL

• Did not earn clinical excellence award – 4 other Baltimore hospitals did• Only award for specialty excellence was for stroke care• One of the lowest rated hospitals in Baltimore

JOHNS HOPKINS HOSPITAL

• Ranked #1 overall, #2 in the nation for neurology and neurosurgery, #3 in cancer, #4 in heart and heart surgery• No other Maryland hospital made the top 50

2005Ratings

Johns Hopkins, transparently

2005

Data limitations

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Some tasks are harderRisk adjustment is an attempt to level the playing field

WHITE COAT NOTES NEWS FROM BOSTON'S MEDICAL AND SCIENTIFIC COMMUNITY;A NEW WAY TO RANK HOSPITAL QUALITY

Boston Globe, March 2, 2004“Tops in Heart Attack Care”• Winchester Hospital• Melrose-Wakefield Hospital• South Shore Hospital• Brockton Hospital• Massachusetts General Hospital (5)• Beth Israel Deaconess (23)• New England Medical Center• Brigham and Women's Hospital (3)• Boston Medical Center• Beverly Hospital

An example of what happens when data are reported without risk adjustment

The hospitals at the top of the list usually

transfer their most serious heart attack

patients to the hospitals lower down.

Risk adjustment

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How consumers view surgeon quality

43 non-MDs and non-RNs were asked to select a surgeon. They were given this chart, assured that there was no right or wrong answer, and asked to list their 1st, 2nd and 3rd choice:

Response Number % of Total

C-A-B 23 53%

B-A-C 9 21%

A-C-B 6 14%

C-B-A 4 9%

B-C-A 1 2%

Number of Cases Deaths Expected O/E ratio**

Mortality*

Surgeon A 100 6 (6%) 4% 1.2

Surgeon B 90 7 (8%) 9% 0.9

Surgeon C 240 14 (5.8%) 3% 1.9 

The Result: All three surgeons were ranked FIRST and LAST by some respondents. Surgeon C was first for 62%. Surgeon B was last for 64%.

Media/consumer understanding

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Adjusted CABG Mortality in Northern New England n=37,599

00

11

22

33

44

55

66

77

88

19881988 19901990 19921992 19941994 19961996 19981998

Mortality Rate (%)

Mortality Rate (%)

20002000

Public reporting

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Uses of Quality Measurement

Results(Performance)

Goals

Purpose

Improvement

MotivationConsumersPurchasersRegulatorsPatientsContractorsReferring CliniciansEtc.

Knowledge About Performance

Measurement for

Selection & Accountability

Selection

Knowledge About Processes and

Results

• Process Improvement• New Design• Process Control

Care Deliver Teams and

Practitioners

Change

Organizations

THE NNE AND NEW YORK STATE EXPERIENCE

MOTIVATION

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Quality Measurement in Aortic Valvuloplasty

• To palliate congenital aortic stenosis, the valve is dilated with a balloon

• Therapeutic success is achieved by maximizing the amount of dilation/gradient relief -- use a bigger balloon

• Safety is achieved by avoiding rupture/damage to the valve -- use a smaller balloon

• Do not measure quality of aortic valvuloplasty purely by procedural morbidity/mortality, need a measure of efficacy and long term benefit as well, otherwise the incentive is purely to use a smaller balloon

Creating conflicts

Lee TH. Torchiana DF. Lock JE. Is zero the ideal death rate?. New England Journal of Medicine. 357(2):111-3, 2007 Jul 12.

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Mom and apple pie?

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There are two groups of PCI (angioplasty) patients

Mom and apple pie?

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There are six times as many PCI patients in shock in MA. Why?

Mom and apple pie?

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Which is preferable?

• A lower mortality rate for PCI?

• A lower mortality rate for MI? Patients who receive PCI for MI with shock

are 67% more likely to be alive after 6 years than those that don’t.*

For 130 of 1000 patients with shock/MI, PCI is the difference between life and death.

Source: JAMA, June 2006

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Provider Behavior - Risk aversion

too well too sick

therapeutic range

benefit

risk

Severity of illness

Risk &benefit

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ImprovementRESEARCH/IMPROVEMENT

PUBLICREPORTING

PAYMENT

ACCOUNTABILITY

Data Quality

Risk Adjustment

Cost

Administrative Data

Clinical Data

.The stakes get higher as the purpose moves towards accountability

Keeping Score in the Transparency Era

A way forward

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Applying the model

Patient safety “never events” – accountability “safe practices” – public reporting (and

payment) Hospital Acquired Infections – public reporting AHRQ Patient Safety Indicators - improvement

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Responding with transparency

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Summary

• Quality measurement has proven value for accountability and care improvement• The notion that transparency and consumerism will add value to healthcare is an attractive but

unproven hypothesis.• But patients will be harmed by poorly thought out reporting

• Avoid zero sum scenarios where one piece of public data improves at the expense of another hidden outcome

• Use statistics appropriately

• Be aware of the limitations of administrative data

• Be careful with reports at the physician level, these are the most likely to change behavior

• Some data can be worse than no data

"…there is nothing either good or bad but thinking makes it so.“Hamlet