The Minnesota Department of Health recently published a report over a 15 month period that documenting 99 events occurring in Minnesota hospitals that should never occur. This included things like wrong-site surgery, pressure ulcers, and misuse of medical devices. Among these events, 20 resulted in a patient death.
- Minnesota hospitals' report on “never events” released. Robeznieks A, Published in Amercian Medical News on February 21,
- Accessed on 2005-02-16. www.ama-assn.org/amednews/2005/02/21/prsc0221.htm
This is an example of the increasing demand that hospitals and other health care organizations produce “report cards” that tell the public how well or poorly they are doing. We need to be cautious about reporting this type of information because if it is presented poorly, it may unfairly taint the reputation of individuals or organizations. In particular, if a group of doctors takes on the most difficult cases because of their unique skill, their rates of adverse outcomes will be higher, unless some risk adjustment is made.
There’s an entire book on risk adjustment,
- Risk Adjustment for Measuring Health Care Outcomes, Third Edition. Iezzoni LI (2003) Chicago, IL: Health Administration Press. ISBN: 156793207X. [BookFinder4U link]
and a lot more research needs to be done on this topic. A recently published article in BMJ about report cards for cardiothoracic surgeons has the following quote:
A BMA spokesperson agreed that patients should have high quality information. However, the BMA would oppose the use of crude mortality data. “Evidence from other countries shows that some surgeons are deterred from taking on very complex and therefore high risk procedures because published simplistic leagues tables count against them,” the spokesperson said. “We are keen to work with the government and patients to develop meaningful and accurate data that will enhance patient choice." bmj.bmjjournals.com/cgi/content/full/330/7488/384-b
Further reading (new reference added March 23, 2005):
- The unintended consequences of publicly reporting quality information. Werner RM, Asch DA. Jama 2005: 293(10); 1239-44. [Medline]
- Creating the evidence base for quality improvement collaboratives. Mittman BS. Ann Intern Med 2004: 140(11); 897-901. [Medline] [Abstract] [PDF]
- Implementation of the ANA Report Card. Moore K, Lynn MR, McMillen BJ, Evans S. Journal of Nursing Administration 1999: 29(6); 48 - 54. [Medline]
- Use of public performance reports: a survey of patients undergoing cardiac surgery. Schneider EC, Epstein AM. Jama 1998: 279(20); 1638-42. [Medline] [Abstract]
- Problems for clinical judgement: 4. Surviving in the report card era. Tu JV, Schull MJ, Ferris LE, Hux JE, Redelmeier DA. Cmaj 2001: 164(12); 1709-12. [Medline] [Abstract] [Full text] [PDF]
- A review of literature on benchmarking [PDF]. Dattakumar R, Dattakumar R, Published in Benchmarking: An International Journal, Vol. 10, No. 3, 2003. pp. 176-209. Accessed on 2004-08-27. www.oulu.fi/w5w/benchmarking/artikkelit/dattakumar.pdf
- Cardiac surgical services in Bristol are now of high quality. [letter]. Willie P, Hughes D. Bmj 1998: 316(7149); 1986. [Medline] [Full text]
- Hospital volume and surgical mortality in the United States. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE. New England Journal of Medical 2002: 346(15); 1128-37. [Medline]
- Views of practicing physicians and the public on medical errors. Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, Altman DE, Zapert K, Herrmann MJ, Steffenson AE. N Engl J Med 2002: 347(24); 1933-40. [Medline]
- The measurement and monitoring of surgical adverse events. Bruce J, Russell EM, Mollison J, Krukowski ZH. Accessed on 2003-08-15. www.ncchta.org/fullmono/mon522.pdf
- Was Bristol an outlier? Carr D. Lancet 2001: 358(9298); 2083; discussion 2084.
- Mortality in Low Birth Weight Infants According to Level of Neonatal Care at Hospital of Birth. Cifuentes J, Bronstein J, Phibbs CS, Phibbs RH, Schmitt SK, Carlo WA. Pediatrics 2002: 109(5); 745-751. [Abstract]
- Five times: coincidence or something more serious? Irving M, Berwick DM, Rubin P, Treasure T. British Medical Journal 1998: 316(7146); 1736. [Full text]
- Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis. Kennedy BP, Kawachi I, Glass R, Prothrow-Stith D. British Medical Journal 1998: 317(7163); 917-21.
- Public confidence and cardiac surgical outcome. Cardiac surgery: the fall guy in medical quality assurance [editorial]. Keogh BE, Dussek J, Watson D, Magee P, Wheatley D. British Medical Journal 1998: 316(7147); 1759-60. [Medline] [Full text] [PDF]
- A broader concept of medical errors. Lee TH. N Engl J Med 2002: 347(24); 1965-7. [Medline]
- Relationship Between Low Quality-of-Care Scores and HMOs' Subsequent Public Disclosure of Quality-of-Care Scores. McCormick D, Himmelstein DU, Woolhandler S, Wolfe SM, Bor DH. Jama 2002: 288(12); 1484-90. [Medline]
- Association of hospital procedure volume and outcomes in patients with colon cancer at high risk for recurrence. Meyerhardt JA, Catalano PJ, Schrag D, Ayanian JZ, Haller DG, Mayer RJ, Macdonald JS, Benson AB, 3rd, Fuchs CS. Ann Intern Med 2003: 139(8); 649-57. [Medline] [Abstract] [Full text] [PDF]
- Nurse-Staffing Levels and the Quality of Care in Hospitals. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. N Engl J Med 2002: 346(22); 1715-1722. [Abstract]
- Putting the patient in patient safety: linking patient complaints and malpractice risk. Sage W. Jama 2002: 287(22); 3003-5.
- Underperforming doctors: a postal survey of the Northern Deanery. Taylor G. Bmj 1998: 316(7146); 1705-8. [Medline] [Abstract] [Full text] [PDF]
- Educational outreach visits: effects on professional practice and health care outcomes. Thomson OBMA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Cochrane 2000: (2); CD000409.
- Annual league tables of mortality in neonatal intensive care units: longitudinal study. International Neonatal Network and the Scottish Neonatal Consultants and Nurses Collaborative Study Group. Parry GJ, Gould CR, McCabe CJ, Tarnow-Mordi WO. British Medical Journal 1998: 316(7149); 1931-5.
- Random Ranking of Hospitals is Unsound. Anderson J, Carling K, Mattson S. Chance 1998: 11(3); 34-39.
- A review of literature on benchmarking [PDF]. Dattakumar R, Dattakumar R, Published in Benchmarking: An International Journal, Vol. 10, No. 3, 2003. pp. 176-209. Accessed on 2004-08-27. www.oulu.fi/w5w/benchmarking/artikkelit/dattakumar.pdf
- The Relation between the Availability of Neonatal Intensive Care and Neonatal Mortality. Goodman DC, Fisher ES, Little GA, Stukel TA, Chang C-h, Schoendorf KS. N Engl J Med 2002: 346(20); 1538-1544. [Medline] [Abstract] [Full text] [PDF]
- Making self regulation credible. Through benchmarking, peer review, appraisal-and management [editorial]. Johnson J. British Medical Journal 1998: 316(7148); 1847-8. [Medline] [Full text]
- Benchmarking Hospital Lengths of Stay Using Histograms. Lagoe RJ. Nursing Economics 1999: 17(2); 75-83. [Medline]
- Reliability of league tables of in vitro fertilisation clinics: retrospective analysis of live birth rates. Marshall EC, Spiegelhalter DJ. British Medical Journal 1998: 316(7146); 1701-4; discussion 1705. [Medline] [Abstract] [Full text] [PDF]
- Annual League Tables of Mortality in Neonatal Intensive Care Units: Longitudinal Study. Parry GJ, Gould C, McCabe C, Tarnow-Mordi WO. British Medical Journal 1998: 316; 1931 - 1935. [Medline] [Abstract] [Full text] [PDF]
- Mortality and volume of cases in paediatric cardiac surgery: retrospective study based on routinely collected data. Spiegelhalter DJ. Bmj 2001: 323; 1-5. [Medline] [Abstract] [Full text] [PDF]
- Practical Benchmarking for Mutual Improvement. Thor CG (1995) Portland, Oregon: Productivity Press.
- Lessons from the Bristol case. More openness--on risks and on individual surgeons' performance [editorial]. Treasure T. Bmj 1998: 316(7146); 1685-6. [Medline] [Full text] [PDF]
You can find an earlier version of this page on my website.