Physician report cards make no difference in referral patterns

Back in 1986, the Health Care Financing Administration launched the brave new era of quality reporting in this country by releasing “report cards” that detailed hospital-specific, risk-adjusted mortality rates for coronary artery bypass graft (CABG) surgery.

Since that time, the number and type of publicly reported quality outcomes has grown exponentially with the goal of helping patients make informed decisions when selecting doctors, thereby driving quality improvement by doctors and hospitals.

Has it worked?

A recent article titled “Influence of Cardiac Surgeon Report Cards on Patient Referral by Cardiologists in New York State After 20 Years of Reporting” (Circulation: Cardiovascular Quality Outcomes, November 2013) suggests that the answer is an emphatic, “No!”

Despite the availability of these report cards, most patients instead entrust their cardiologists with selecting surgeons on their behalf — and, although most cardiologists are aware of cardiac surgery report cards, they are rarely influenced by them when referring their patients.

In their survey, authors David L. Brown, Arnold M. Epstein and Eric Schneider found that although almost all cardiologists (94%) were aware of cardiac surgeon report cards, a mere 25% reported being moderately or substantially influenced by them in their referral decisions.

Further, 75% of cardiologists said that they did not discuss these report cards with any of their patients — and, shockingly, only 34% reported that the quality of the cardiac surgeon to whom they most commonly refer was among the best available.

Clear differences were found among cardiologists who reported being influenced to a greater degree by the report cards.

Age, practice of general cardiology, and employment by a hospital or health system were independently associated with greater influence by report card data — interestingly, board certification was associated with lesser influence.

The bottom line is that, even though the Centers for Medicaid and Medicare Services collects and publicly reports national hospital data on CABG mortality and other quality measures, physicians remain mistrustful of these data or cling to familiar referral patterns or both.

While some proponents of report cards believe that their value lies primarily in bringing about quality improvement at the hospital level, just think how much greater the impact would be if cardiologists used them for guidance in making referrals.

With surgical errors continuing at an alarming rate — according to one report, 80 “never events” per week in the nation’s operating rooms – it seems appropriate to take a more critical look at our “business as usual” practices.

If favoritism still trumps quality in the face of clear evidence, I see it as a significant policy issue that requires serious attention.

David B. Nash is founding dean, Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, PA, and blogs at Nash on Health Policy and Focus on Health Policy.

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