The use of public performance reporting by general practitioners: a study of perceptions and referral behaviours

The elicitation of patient and physician preferences for calculating consumer-based composite measures on hospital report cards: results of two discrete choice experiments

PURPOSE

The calculation of aggregated composite measures is a widely used strategy to reduce the amount of data on hospital report cards. Therefore, this study aims to elicit and compare preferences of both patients as well as referring physicians regarding publicly available hospital quality information METHODS: Based on systematic literature reviews as well as qualitative analysis, two discrete choice experiments (DCEs) were applied to elicit patients' and referring physicians' preferences. The DCEs were conducted using a fractional factorial design. Statistical data analysis was performed using multinomial logit models RESULTS: Apart from five identical attributes, one specific attribute was identified for each study group, respectively. Overall, 322 patients (mean age 68.99) and 187 referring physicians (mean age 53.60) were included. Our models displayed significant coefficients for all attributes (p < 0.001 each). Among patients, "Postoperative complication rate" (20.6%; level range of 1.164) was rated highest, followed by "Mobility at hospital discharge" (19.9%; level range of 1.127), and ''The number of cases treated" (18.5%; level range of 1.045). In contrast, referring physicians valued most the ''One-year revision surgery rate'' (30.4%; level range of 1.989), followed by "The number of cases treated" (21.0%; level range of 1.372), and "Postoperative complication rate" (17.2%; level range of 1.123) CONCLUSION: We determined considerable differences between both study groups when calculating the relative value of publicly available hospital quality information. This may have an impact when calculating aggregated composite measures based on consumer-based weighting.

A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies

BACKGROUND

The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process.

METHODS

A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis.

RESULTS

A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified.

CONCLUSIONS

Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.

Perspective of potential patients on the hospital volume-outcome relationship and the minimum volume threshold for total knee arthroplasty: a qualitative focus group and interview study

BACKGROUND

Total knee arthroplasty (TKA) is performed to treat end-stage knee osteoarthritis. In Germany, a minimum volume threshold of 50 TKAs/hospital/year was implemented to ensure outcome quality. This study, embedded within a systematic review, aimed to investigate the perspectives of potential TKA patients on the hospital volume-outcome relationship for TKA (higher volumes associated with better outcomes).

METHODS

A convenience sample of adults with knee problems and heterogeneous demographic characteristics participated in the study. Qualitative data were collected during a focus group prior to the systematic review (n = 5) and during telephone interviews, in which preliminary results of the systematic review were discussed (n = 16). The data were synthesised using content analysis.

RESULTS

All participants (n = 21) believed that a hospital volume-outcome relationship exists for TKA while recognising that patient behaviour or the surgeon could also influence outcomes. All participants would be willing to travel longer for better outcomes. Most interviewees would choose a hospital for TKA depending on reputation, recommendations, and service quality. However, some would also choose a hospital based on the results of the systematic review that showed slightly lower mortality/revision rates at higher-volume hospitals. Half of the interviewees supported raising the minimum volume threshold even if this were to increase travel time to receive TKA.

CONCLUSIONS

Potential patients believe that a hospital volume-outcome relationship exists for TKA. Hospital preference is based mainly on subjective factors, although some potential patients would consider scientific evidence when making their choice. Policy makers and physicians should consider the patient perspectives when deciding on minimum volume thresholds or recommending hospitals for TKA, respectively.

Mechanisms and impact of public reporting on physicians and hospitals' performance: A systematic review (2000-2020)

BACKGROUND

Public performance reporting (PPR) of physician and hospital data aims to improve health outcomes by promoting quality improvement and informing consumer choice. However, previous studies have demonstrated inconsistent effects of PPR, potentially due to the various PPR characteristics examined. The aim of this study was to undertake a systematic review of the impact and mechanisms (selection and change), by which PPR exerts its influence.

METHODS

Studies published between 2000 and 2020 were retrieved from five databases and eight reviews. Data extraction, quality assessment and synthesis were conducted. Studies were categorised into: user and provider responses to PPR and impact of PPR on quality of care.

RESULTS

Forty-five studies were identified: 24 on user and provider responses to PPR, 14 on impact of PPR on quality of care, and seven on both. Most of the studies reported positive effects of PPR on the selection of providers by patients, purchasers and providers, quality improvement activities in primary care clinics and hospitals, clinical outcomes and patient experiences.

CONCLUSIONS

The findings provide moderate level of evidence to support the role of PPR in stimulating quality improvement activities, informing consumer choice and improving clinical outcomes. There was some evidence to demonstrate a relationship between PPR and patient experience. The effects of PPR varied across clinical areas which may be related to the type of indicators, level of data reported and the mode of dissemination. It is important to ensure that the design and implementation of PPR considered the perspectives of different users and the health system in which PPR operates in. There is a need to account for factors such as the structural characteristics and culture of the hospitals that could influence the uptake of PPR.

The impact of public performance reporting on cancer elective surgery waiting times: a data linkage study

Background

Excessive waiting times for cancer elective surgery are a concern in publicly funded healthcare systems. Several countries including Australia have introduced healthcare reforms involving time-based targets and public performance reporting (PPR) of hospital data. However, there is mixed evidence of their benefits. We sought to examine the impact of targets and PPR of cancer elective surgery waiting times on access to breast, bowel and lung cancer elective surgery.

Methods

We analysed routinely-collected linked data on admissions and waiting times for patients aged 15 years or over (n = 199,885) who underwent cancer surgery in a public hospital in Victoria, Australia over a 10-year period. We conducted difference-in-differences analyses to compare waiting times before (2006–07 to 2011–12) and after (2012–13 to 2015–16) the introduction of PPR in meeting these targets.

Results

Across all cancer types, urgent patients were all treated within 30 days before and after PPR. Following PPR, there was a slight increase in the mean waiting times across all cancer types and urgency categories. Patients with lung cancer waited on average two and half days longer for treatment and patients with breast cancer waited on average half-a-day less. There was no effect of PPR on waiting times for patients with bowel cancer across urgency categories.

Conclusions

Our findings suggest that time-based targets and PPR had minimal impact on surgical waiting times. This may be due to reasonable waiting times prior to PPR, improved efficiency being masked by 20% growth in the population, lack of public knowledge that waiting times are publicly reported, or lack of real-time reporting to drive behavioural change. The use of generic elective surgery recommended waiting time measures for cancer is discussed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06132-w.

Public disclosure of hospital clinicians' performance data: insights from medical directors

Objective This study gathered information from public hospital chief medical officers to better understand underlying mechanisms through which public reporting affects institutional behavioural change and decision making towards quality improvement. Methods This qualitative study used thematic analysis of 17 semistructured, in-depth interviews among a peak group of medical directors representing 26 health services in Victoria, Australia. Results The medical directors indicated a high level of in-principle support for public reporting of identifiable, individual clinician-level data. However, they also described varying conceptual understanding of what public reporting of performance data is. Overall, they considered public reporting of individual clinicians' performance data a means to improve health care quality, increase transparency and inform consumer healthcare decision making. Most identified caveats that would need to be met before such data should be publicly released, in particular the need to resolve issues around data quality and timeliness, context and interpretation and ethics. Acknowledgement of the public's right to access individual clinician-level data was at odds with some medical directors' belief that such reporting may diminish trust between clinicians and their employers, thus eroding rather than motivating quality improvement. Conclusions Public reporting of identifiable individual healthcare clinicians' performance data is an issue that merits robust research and debate given the effects such reporting may have on doctors and on hospital quality and safety. What is known about the topic? The public reporting of individual clinician-level data is a mechanism used in some countries, but not in Australia, for increasing health care transparency and quality. Clinician-level public reporting of doctors' performance attracts contention and debate in Australia. What does this paper add? This paper informs debate around the public reporting of individual clinician-level performance data. Among a discrete cohort of senior hospital administrators in Victoria, Australia, there was strong in-principle support for such public reporting as a means to improve hospital quality and safety. What are the implications for practitioners? Before public reporting of individual clinician performance data could occur in Australia, resolution of issues would be required relating to legality and ethics, data context and interpretation, data quality and timeliness.

Characteristics and decision making of hospital report card consumers: Lessons from an onsite-based cross-sectional study

BACKGROUND

Hospitals report cards (HRCs) have had little impact on the hospital choice of patients. Thus, health policy makers should learn more about HRC consumers to better understand how to present and target hospital-related quality information.

OBJECTIVE

We sought to learn more about consumers of HRCs and determine the impact of the complexity and tailoring of HRCs on the hospital choice.

METHODS

We used primary data drawn from an onsite-based survey, conducted in 2017 at Germany's premier portal, Weisse Liste (N = 635). We performed hierarchical multivariate logistic regression models to identify main predictors associated with hospital choices.

RESULTS

HRC consumers differ from the national online population and the national population in general. Eighty percent of those patients or family members, who have used a HRC before, confirmed an impact on the hospital choice. The quality of hospital choices decreased with an increasing level of complexity (p < .001); the latter was identified as a significant predictor for making good choices. However, tailoring HRCs did not have an impact on the quality of the hospital choice (p > .05).

CONCLUSIONS

HRCs have a significant impact on the hospital choice among report card consumers. Health policy makers might focus on decreasing the level of complexity; this, more than tailoring report cards, may help consumers make good hospital choices.

The impact of Australian healthcare reforms on emergency department time-based process outcomes: An interrupted time series study

Background

In 2011, the Australian government introduced national healthcare reforms aimed at increasing the timeliness and quality of hospital care. The healthcare reforms included, but were not limited to, emergency department (ED) time-based targets, financial incentives, and public performance reporting of hospital data. We sought to evaluate the impact of the national healthcare reforms on ED time-based process outcomes.

Methods

A quasi-experimental study of ED presentations from 2006 to 2016 in the state of Victoria, Australia. Uncontrolled, interrupted time-series analyses were used to evaluate, by hospital peer groups, the effect of national healthcare reforms on: patient wait times for treatment; treatment within recommended time; and patient departure within four hours of arrival in ED.

Results

There were small improvements in ED time-based process outcomes following the introduction of the national healthcare reforms. These occurred in most hospital peer groups immediately and over the longer term, across the various triage categories. The largest improvements occurred in small hospitals and smallest improvements in medium sized hospitals. ED time-based targets, now abolished by the Australian government, were not achieved in any hospital peer groups.

Conclusions

Our findings suggest that national healthcare reforms had the potential to prompt fundamental changes in ED processes leading to significant improvements in ED performances across most hospital peer groups but were generally unable to reach the ED targets imposed nationally. ED performances also varied by hospital peer groups. Attention to ED time-based process outcomes within hospital peer groups may provide insights into hospital practices that could improve the quality and efficiency of ED care.

Public reporting of hospital quality data: What do referring physicians want to know?

OBJECTIVE

To identify ambulatory care physicians' priorities for hospital quality criteria to support them in counselling patients what hospital to choose.

METHODS

Three hundred non-hospital-based stratified randomly sampled physicians, representing the five main referring specialties in Germany participated in a cross-sectional survey. Physicians rated the importance of 80 hospital quality criteria to be used in their counselling of patients in need of hospital care. Criteria selection was based on a literature analysis and the content of Germany's mandatory hospital quality reports. We calculated the most important criteria and performed an ordinal regression analysis to examine whether the physicians' characteristics 'age', 'sex', 'specialty', 'practice type' and 'region' affected physicians' importance ratings.

RESULTS

To counsel patients in need of a hospital referral, physicians preferred hospital quality criteria that reflect their own and their patients' experiences with a hospital. Additionally, hospitals' expertise and results of treatment were rated highly important. In contrast, hospitals' structural characteristics and compliance with external requirements were rated less important. Physicians' characteristics affected importance ratings only negligibly.

CONCLUSIONS

To support referring physicians' counselling of patients regarding what hospital to choose in order to achieve optimal patient outcomes eventually, hospital report cards must be enriched by information on physicians' and their patients' experiences with hospitals. Hospitals' structural characteristics play a minor role in counselling of patients needing hospital care.

Public performance reporting and hospital choice: a cross-sectional study of patients undergoing cancer surgery in the Australian private healthcare sector

OBJECTIVES

National mandatory public performance reporting (PPR) for Australian public hospitals, including measures of cancer surgery waiting times, was introduced in 2011. PPR is voluntary for private hospitals. The aims of this study were to assess whether PPR of hospital data is used by patients with breast, bowel or lung cancer when selecting a hospital for elective surgery and how PPR could be improved to meet their information needs.

DESIGN

A national cross-sectional postal questionnaire.

SETTING

Australian private healthcare sector.

PARTICIPANTS

Private patients with breast, bowel or lung cancer who attended a public or private hospital for elective surgery (n=243) in 2016.

OUTCOME MEASURES

Patients' choice of hospital, use of PPR information and preferred areas of PPR information. Descriptive and conventional qualitative content analyses were conducted.

RESULTS

Two hundred and twenty-eight respondents (94%) attended a private hospital. Almost half could choose a hospital. Choice of hospital was not influenced by PPR data (92% unaware) but by their specialist (90%). Respondents considered PPR to be important (71%) but they did not want to see the information, preferring their general practitioners (GPs) to tell them about it (40%). Respondents considered surgery costs (59%), complications (58%) and recovery success rates (57%) to be important areas of information that should be publicly reported. Almost half suggested that quality indicators should be reported at the individual clinician level. Analysis of the open-ended questions identified four themes: (1) decision-making factors; (2) data credibility; (3) unmet information needs and (4) unintended consequences.

CONCLUSIONS

PPR of hospital data had no substantial impact on patients' choice of hospital. Nonetheless, many respondents expressed interest in using it in future. To increase PPR awareness and usability, personalised and integrated information on cost and quality of hospitals is required. Dissemination of PPR information via specialists and GPs could assist patients to interpret the data and support decision-making.