1 The Role of Hospital Transparency

2 The Problem

3 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

4 The Provider’s dilemma

5 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

6 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 Ratings Johns Hopkins, transparently 2005 Data limitations

7 Some tasks are harder Risk 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

8 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 1 st, 2 nd and 3 rd choice: ResponseNumber% of Total C-A-B2353% B-A-C921% A-C-B614% C-B-A49% B-C-A12% Number of CasesDeaths Expected O/E ratio** Mortality* Surgeon A100 6 (6%) 4% 1.2 Surgeon B90 7 (8%) 9% 0.9 Surgeon C (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

9 Adjusted CABG Mortality in Northern New England n=37, Mortality Rate (%) 2000 Public reporting

10 Uses of Quality Measurement Results (Performance) Goals Purpose Improvement Motivation Consumers Purchasers Regulators Patients Contractors Referring Clinicians Etc. 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

11 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.

12 Mom and apple pie?

13 There are two groups of PCI (angioplasty) patients Mom and apple pie?

14 There are six times as many PCI patients in shock in MA. Why? Mom and apple pie?

15 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

16 Provider Behavior - Risk aversion too well too sick therapeutic range benefit risk Severity of illness Risk & benefit

17 Keeping Score in the Transparency Era A way forward

18 Applying the model Patient safety  “never events” – accountability  “safe practices” – public reporting (and payment)  Hospital Acquired Infections – public reporting  AHRQ Patient Safety Indicators - improvement

19 Responding with transparency

20 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