JAMA study: Jury still out on health "report cards"

Enthusiasm for public health care reporting should not interfere with the stated goal of such reporting: Improving health care quality.

That was the message of a special communication published in the Journal of the American Medical Association March 9, which noted that the positive impact of public reporting of health care outcome and quality-measure data "is assumed but has not been demonstrated."

In fact, lead author Rachel M. Werner, MD, PhD, cautioned that reporting could have unintended consequences such as physicians choosing patients based on their risk profile, the performance of unnecessary procedures to achieve target rates and the discounting of clinician judgment and patient preference.

"We have to stop assuming that physician report cards are good," said Dr. Werner, a staff physician at the Philadelphia Veterans Affairs Medical Center and an assistant professor in the division of general internal medicine at the University of Pennsylvania in Philadelphia. "We need to improve them to make them live up to their goal of improving quality."

Physician and hospital report cards have emerged in the last decade as health plans, self-insured corporations and consumers have sought information on which doctor or facility is the "best."

Although polls indicate that there is broad support, Dr. Werner said studies show that report cards are not widely understood or used by patients in making care decisions. She also cited studies showing that they are not widely used by referring physicians or by health plans in surgical contract decisions.

Dr. Werner said the number of patients who had seen quality reports has increased from 27% in 2000 to 35% in 2004. Of the patients who do use the reports to make choices, she said, most tend to focus on measures of patient satisfaction, waiting times and physician accessibility and not on "technical" data.

Yet there is some limited evidence that reporting of outcomes and quality measures improves accountability and public trust, Dr. Werner said.

She added that there also was limited data suggesting that reporting might improve care by sparking quality initiatives, providing remediation for poor performers, and restricting physician and hospital practices so they no longer provide care in areas in which they received poor ratings.

Nevertheless, for report cards to serve as a true catalyst for improvement, Dr. Werner said, they need to be credible and widely promoted and understood; there needs to be better adjustment for severity of illness, comorbidities and economic status so there is less incentive to cherry-pick patients; and reporting must be mandatory and universal. Otherwise, poor performers have an incentive not to provide data for reports.

AMA Secretary John H. Armstrong, MD, praised Dr. Werner's analysis and said private feedback to physicians had shown to be more beneficial than public reporting of an individual physician's outcomes or adherence to quality measures.

"Quality improvement is a systems issue -- physicians must be assessed in groups and across health care systems," Dr. Armstrong said. "Focusing on systems of care recognizes that quality improvement depends on all elements of the system."

He warned against reporting systems that distort the physician-patient relationship by the unintended creation of incentives to disenfranchise vulnerable and sicker patient populations and apply inappropriate interventions to achieve a certain sample size.

"There is a complexity to reporting that must be acknowledged so that any reporting system has the intended effect of quality improvement -- which the AMA defines as better and safer care," Dr. Armstrong said. "Our general sense is that [Dr. Werner's] article provided a useful analysis to enlighten the discussion of public reporting."