Public reporting of hospital quality data: What do referring physicians want to know?
Introduction
Providing consumers with publicly reported performance information on health care providers is considered a key element of optimal health care quality [[1], [2], [3], [4], [5]]. Based on Donabedian’s framework for the evaluation of quality of medical care [6] including the assessment of structures, processes, and outcomes of care, various further models have been proposed regarding the content of public quality reports. Most of them concentrate on the core quality dimensions ‘effectiveness’, ‘safety’, and ‘responsiveness/patient-centredness’, in line with the OECD Health Care Quality Indicators (HCQI) Framework [7,8]. Increased transparency in these dimensions of quality of care could contribute to quality improvement when following two linked and potentially synergistic pathways: (1) selection of better performing providers of care or (2) process changes to improve quality [9]. Publicly reported performance information could be used by purchasers, regulators, and providers to serve purposes such as developing quality-focused contracts; efficiency in purchasing and the provision of services; responsiveness of providers; accountability of providers; benchmarking; performance improvement; and allowing providers to use results as marketing tools [10]. Still, the central purpose of public reporting to impact on clinical outcomes remains consumer participation through informed decision-making [[11], [12], [13]]. Today, many healthcare systems use public reporting, especially hospital quality reports. However, to date, only moderate progress has been made in stimulating patients to choose their provider of care based on publicly reported comparative performance data [11,14,15]. Among the reasons for the poor adoption of report cards are weaknesses in report card content, design, complexity, and accessibility, leading to a lack of knowledge and understanding of the available information [11,[16], [17], [18]]. Physicians typically raise concern over the validity and reliability of the reported data, which in part may be attributable to insufficient case-mix adjustment and small sample sizes [[19], [20], [21], [22]]. The common process of choosing a hospital may also explain poor adoption of report cards. If able to choose freely, most patients rely on former personal experiences and recommendations by relatives and ambulatory care physicians [[23], [24], [25], [26], [27]].
Consequently, several authors suggested ways to improve report cards for patients [14,18,28]. Another way to increase hospital quality reports’ impact on healthcare quality may be to redirect the performance data. Targeting referring physicians as well, facilitates the use of public reports in their counselling of patients concerning hospital stays [10,24,25,[29], [30], [31]].
However, there is a lack of research about quality criteria physicians consider in counselling their patients in need of a specialist or hospital referral [32,33]. Present research on quality criteria used in report cards focusses on patient preferences for hospital quality of care data. Only few studies have focussed on referring physicians as addressees of comparative performance data on healthcare providers, showing almost no use of publicly available performance data [32,[34], [35], [36], [37], [38]]. Thus, physicians seem to prefer the courtesy and helpfulness of staff, physicians’ ability to communicate effectively with patients and physicians’ ability to show care, concern and empathy as quality criteria [39,40]. Other studies emphasise the importance of physicians’ previous experiences, especially the importance of the communication process between referring physicians and hospitals [[41], [42], [43]].
When targeting physicians as addressees of comparative performance data, it is important to consider potentially differential information needs in subgroups of physicians. Javalgi et al. [44] found that primary care or older physicians were less technical/clinical- and more service-oriented than their non-primary care or younger colleagues. Roter et al. [45] noted that female primary care physicians communicate more patient-centred, which might influence their ratings of the importance of patient-centredness as a quality criterion. The same holds true for physicians in group practices who adopt more patient-centred care practices than solo physicians [46]. The localisation of a practice might also be a source of differences between importance ratings, especially in Germany. More than 25 years after reunification of the former East and West federal states, huge regional variations are still present in health care [47]. Therefore, in studying the information preferences of physicians in relation to hospital quality criteria, the mentioned physician and practice characteristics should be considered.
In Germany, informing physicians about hospital quality plays a special role. In this case, office-based physicians represent one of the officially appointed addressees of the mandatory hospital quality reports. The reports, introduced by law in 2004, include a variety of structural and performance data. Using these data, the Federal and 17 Regional Associations of Statutory Health Insurance Physicians (ASHIP) are supposed to provide comparative data on hospitals’ performance to all office-based physicians.
However, not only in Germany do physicians play a prominent role in counselling patients where to go for inpatient treatment. Although comparative hospital quality data are available in a growing number of countries, we do not know what information is important for physicians. Therefore, we asked physicians to rate the importance of hospital quality criteria for their counselling of patients and evaluated the influence of selected physician and practice characteristics on the ratings.
Section snippets
Study design
In a cross-sectional observational study, we interviewed a stratified random sample of referring physicians working in ambulatory care in Germany.
Participants
We surveyed office-based physicians without hospital privileges working in Germany’s ambulatory care setting. Because only 4% of all office-based physicians in Germany have hospital privileges, physicians usually refer their patients for inpatient care. We focused on general practitioners, internists, gynaecologists, orthopaedists and surgeons. These
Physicians’ preferences for hospital quality criteria
In total, 23 out of 80 quality criteria yielded a mean rating of ≥4.0 (important or very important) (Table 1).
On average, these 23 criteria were rated ‘important’ by more than 75% of the participating 300 physicians. The number of hospital quality criteria that were rated ‘important’ by more than half of the participants amounted to 45 criteria (Appendix 2).
All criteria yielding a mean rating of ≥4.0 belonged to four of the six dimensions, namely “experiences”, patient centredness”, “expertise”
Discussion
Regardless of their age, sex, specialty, region of practice or practice type, non-hospital-based physicians agree in principle about the most important quality criteria on which they prefer to counsel their patients in need of hospital care. They favour hospital quality criteria that reflect their own and their patients’ experiences with a hospital. Additionally, a hospital’s expertise and the results of treatment play a significant role in physicians’ counselling of patients what hospital to
Conclusions
To support referring physicians in their counselling of patients what hospital to choose and to achieve the optimal outcomes eventually, today’s hospital report cards must be changed. Instead of predominantly reporting structural characteristics of hospitals, reports need to be enriched by information on physicians’ and their patients’ experiences with hospitals. Accordingly, surveys of physicians’ experiences with hospitals should accompany hospital report card initiatives. Referring
Funding
This work was supported by a health services research grant of the German Federal Chamber of Physicians (grant 07-003). The sponsor was not involved in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
Competing interests
The authors have no competing interests.
Acknowledgements
The authors wish to thank Prof Frank Krummenauer and Dr Henrike Feuersenger (Department for Medical Biostatistics and Epidemiology of Witten/Herdecke University) for their statistical support. The authors also wish to thank the Associations of SHI physicians of Lower Saxony, Baden-Württemberg, Saxony and Thuringia and all participating physicians.
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