Quality/Medical Errors

Publicly reporting quality information may inadvertently reduce, rather than improve, care quality

Health care report cards publicly report information about physician, hospital, and health plan quality in an attempt to improve quality. The goal is to help patients, referring physicians, and health care purchasers to select high-quality physicians and to motivate physicians to improve their care quality. However, the value of publicly reporting quality information is largely undemonstrated. It may even inadvertently reduce, rather than improve, quality of care, caution University of Pennsylvania researchers, Rachel M. Werner, M.D., Ph.D., and David A. Asch, M.D., M.B.A., in a recent paper.

Unintended negative consequences include causing physicians to avoid sick patients in an attempt to improve their quality ranking, encouraging physicians to achieve "target rates" for health care interventions even when it may be inappropriate among some patients, and discounting patient preferences and clinical judgment. Given these limitations, the researchers believe it may be necessary to reassess the role of public quality reporting in quality improvement.

In a second paper, Drs. Werner and Asch and their colleague, Daniel Polsky, Ph.D., present the results of their study of the effects of report cards on racial disparities in coronary artery bypass graft (CABG) surgery. The researchers found that the publishing 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. This racial and ethnic disparity in CABG use in New York significantly increased after that State's CABG report card was released, whereas disparities did not change significantly in comparison States that did not release report cards. Over time, this increase in racial and ethnic disparities decreased to levels similar to those before the release of report cards.

The researchers suggest that including measures of the appropriateness of care might improve report cards. In the case of CABG report cards, appropriateness criteria would diminish surgeons' incentive to substitute potentially less appropriate low-risk patients for potentially more appropriate high-risk patients. Focusing the attention of report cards on processes of care rather than patient outcomes would also reduce patient avoidance. Finally, releasing the information only to physicians who are being rated might encourage them to improve their performance without giving them an incentive to avoid patients they perceive as being high risk. Both studies were supported in part by the Agency for Healthcare Research and Quality (T32 HS00009).

For details, see "The unintended consequences of publicly reporting quality information," by Drs. Werner and Asch, in the March 9, 2005, Journal of the American Medical Association 293(10), pp. 1239-1244; and "Racial profiling: The unintended consequences of coronary artery bypass graft report cards," by Drs. Werner, Asch, and Polsky, in the March 15, 2005, Circulation 111, pp. 1257-1263.

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