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'Report cards' don't improve cardiac care.

Public release of hospital "'report cards" did not measurably improve indicators of care for acute MI or chronic heart failure, according to a Canadian study.

Even though most of the hospitals involved in the study undertook at least one quality improvement initiative in response to the report cards, only 1 of 12 indicators of care for acute MI and only 1 of 6 indicators of care for chronic heart failure improved, said Dr. Jack V Tu, a professor in the department of health policy, management, and evaluation at the University of Toronto, and his associates.

Proponents of such report cards maintain that publicly releasing hospital performance data will increase "the accountability and transparency of the health care system," thereby stimulating hospitals and clinicians to improve their performance.

However, "'no large randomized clinical trials have been conducted to evaluate the effectiveness of public report cards as a method for improving quality of care," the investigators said.

They performed such a trial at 81 Ontario hospitals, focusing on cardiac care because of the well-known gap between ideal practice and actual practice in patients hospitalized with acute MI or chronic heart failure.

At each hospital, a sample of 125 charts from 1999-2001 was reviewed. Participating hospitals were randomly assigned to receive early feedback (in October 2003, before the results were released to the public and received extensive media coverage in January 2004) or delayed feedback (in September 2005, at the same time as their results were released to the public but without any media coverage) on a publicly released report card of their performance in the reviewed cases.

Follow-up performance data was obtained on 15,997 patients treated for the same conditions at the same hospitals in 2004-2005.

Despite the fact that many hospitals (73%) that received early feedback changed order sets and/or clinical pathways or care maps for these patient groups during that interval, there was no significant change over time in performance for either the early-feedback or the late-feedback groups.

Only 1 of 12 factors measured in patients with acute MI--the percentage of patients receiving fibrinolytic therapy before transfer to a coronary care or intensive care unit--improved significantly more with early feedback. Similarly, only 1 of 6 factors measured in patients with chronic heart failure--the rate of ACE inhibitor or angiotensin II receptor blocker use in those with left ventricular dysfunction--improved significantly more with early feedback.

These findings "suggest that public release of hospital-specific performance data may not be a particularly effective system-wide intervention for measurably improving processes of care" for either of these conditions, Dr. Tu and his associates said (JAMA 2009 Nov. 18; doi: 10.1001/jama.2009.1731). The study was released online simultaneously with Dr. Tu's presentation of the data at the annual scientific sessions of the American Heart Association.

An unexpected finding was that several hospitals (47%) in the delayed-feedback group started quality improvement initiatives after learning about the public release of report cards for other hospitals but before receiving their own results, the investigators said.

A limitation of this study was that it involved one-time-only report cards. "It is possible that more frequent and timely feedback of publicly released report cards on a regular basis might have been more effective," they added.

Dr. Tu reported no financial conflicts of interest.
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Title Annotation:PRACTICE TRENDS
Author:Moon, Mary Ann
Publication:Family Practice News
Geographic Code:1CANA
Date:Dec 1, 2009
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