No Reduction in Hospital Death Rates After Public Reporting

Bridget M. Kuehn

May 31, 2016

Mandatory public reporting of hospital mortality rates does not appear to improve them, according to a study published online May 31 in the Annals of Internal Medicine. In fact, improvements in mortality rates actually slowed after mandatory reporting began.

In 2008, the Centers for Medicare & Medicaid Services (CMS) began requiring that hospitals publicly report 30-day mortality rates for acute myocardial infarction, congestive heart failure, and pneumonia on CMS' Hospital Compare website. Previously, hospitals had only been required to report process-of-care metrics related to these three conditions. There is wide public support for such efforts to increase transparency about hospital performance as a way to boost the quality of care, write lead author Karen E. Joynt, MD, MPH, from the Harvard School of Public Health in Cambridge, Massachusetts, and colleagues.

"Although the idea that public reporting could improve patient outcomes has strong face validity, there has been surprisingly little evidence that it has actually done so," the authors note.

To assess the effects of mandatory reporting on patient outcomes, Dr Joynt and colleagues compared 30-day mortality trends for acute myocardial infarction, congestive heart failure, and pneumonia before and after mandatory reporting of these values went into effect. To do this, they analyzed administrative data on all hospitalizations for more than 20 million Medicare beneficiaries receiving fee-for-service care at 3970 hospitals between January 2005 and November 2012.

When only process-of-care metrics were reported between 2005 and 2007, the absolute rate of mortality decreased 0.23% per quarter. However, between 2008 and 2012, when both process-of-care and mortality rates were being reported, declines in absolute mortality slowed to just 0.09% per quarter. This represented a change of 0.13% per quarter (95% confidence interval [CI], 0.12% - 0.14%).

For eight conditions without mandatory reporting requirements, the researchers saw a less dramatic slowing of mortality rate improvements, with decreases of 0.17% per quarter before 2008 and decreases of 0.11% after (a 0.06% change per quarter; 95% CI, 0.05% - 0.07%).

When the investigators looked at the mortality trends for individual conditions, they saw that all were unchanged or worse after mandatory mortality reporting began, with the exception of esophageal or gastric diseases.

The authors conclude that it was unlikely that the lack of improvement in mortality signaled that hospitals had reached the "lower limit of what is achievable" because some hospitals had mortality rates much lower than average.

"We are unsure why public reporting of mortality rates has not accelerated overall improvements in this outcome for reported conditions in U.S. hospitals," the authors write. "One would surmise that public reporting ought to work through a 'peer pressure' scenario, in which hospital leaders' knowledge that their performance will be publicly viewable by their peer institutions motivates them to improve their outcomes."

However, the authors explained that only 2% to 3% of hospitals rank as being worse than expected for any condition in a year. So, there may be little incentive for hospitals to invest in quality improvement efforts if nearly all are being ranked as average or above.

"It is also possible that public reporting did not have a major effect on mortality rates overall because hospital leaders are not convinced that their peers or other important stakeholders will see their data or hold them accountable," the authors note.

The study was funded by the National Heart, Lung, and Blood Institute. The authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online May 31, 2016. Abstract

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