The demand for public reporting of clinical performance is understandable, but will it result in the right kind of transparency, ask Jonathan Gabe, Mark Exworthy and Ian Rees Jones
Public reporting of clinical performance is not new. Florence Nightingale and others tried to introduce it, and surgeons in the US have been reporting their performance for over 20 years.
The announcement that public reporting would be introduced in 10 surgical sub-specialties in England, with the first tranche of data being published today, and that surgeons who blocked mortality data would be named, follows many years of audit and public reporting by cardiac surgeons.
‘The performance of schools is not presented by individual teachers’
While transparency can be positive in identifying and preventing poor or even criminal practice, public reporting brings important consequences that are often overlooked.
Public reporting may have contributed to reducing mortality rates from surgery, but it is uncertain how far such reporting contributed to already falling rates. Public reporting can also play a role in helping to restore the public’s trust in health services and health professions in the light of medical scandals such as Bristol or Mid Staffordshire, which themselves largely revolved around “high” mortality rates.
Recent media attention has focused on the apparent voluntary nature of reporting. In the past, it was often not made clear that performance data of some surgeons were missing. The “voluntary” nature of reporting rested on the origins of the scheme in surgical audit, which had been mainly for the purpose of education and peer review.
Our research, funded by the Economic and Social Research Council and Gerneral Medical Council, found that the mortality rates of about one in six surgeons were not publicly available in the late 2000s (and recently it was reported that only 4 per cent had not disclosed).
Organisational culture against disclosure?
Non-disclosure was not randomly distributed but tended to cluster in centres, possibly implying an organisational culture against disclosure. Our respondents also revealed that some surgeons had resigned from their professional body, the Society for Cardio-Thoracic Surgery, over the introduction of rates for named individual surgeons.
Mortality rates have the appearance of an unequivocal measure, and the 30 day post-operation mortality rate is widely adopted. Rates have been falling for many years thanks to advances in surgical practice and new technologies; the national mortality rate is 1.5 per cent (isolated coronary artery bypass graft; 2008).
While falling rates are positive, this creates a dilemma for public reporting as the variation in rates becomes smaller, and so distinguishing meaningfully between surgeons even harder. The use of patient reported outcome measures (PROMs), which measure a patient’s self-reported health or quality of life, thus becomes more significant.
The junior role
Naming surgeons may indicate transparency, but it potentially misleads because the performance of junior surgeons is ascribed to their seniors. This may prompt seniors to take on high risk cases in case the “poor” performance of juniors reflects badly on them. Alternatively, it may prompt closer supervision of the juniors.
Nonetheless, attributing the complexities of healthcare to a named individual might seem invidious. Nurses, referring physicians or the use of operating theatre time might contribute to specific surgical outcomes. In contrast, the performance of schools is not presented by individual teachers.
As with any performance measure such as league tables, there is a normal distribution. It is unclear how far public reporting is moving the whole curve to the right (ie improving the quality of all surgeons) and/or ensuring the outliers (“poor” performers) are removed or their practice improved. Public reporting may reduce variation around the mean.
‘Public reporting is a dynamic picture, reflecting the actions and reactions of patients, surgeons, managers and the government’
The internet has been transformative in accelerating public reporting. However, the presentation of data has often remained esoteric and passive. Comparisons have not been easy. The process of case mix adjustment can remain opaque, and may even reduce transparency.
US evidence suggests that patients do not generally use publicly reported data of surgeons in decision making: their “choice” is mediated by factors such as the limits of their health insurance programme. In the UK, we found that patients have tended not to use such data, and even managers have been reluctant to do so.
Mid Staffordshire may change things utterly (as did Bristol before). Regulators, managers and the public may now be much more willing to investigate rates that may influence their decision. The average age of cardiac surgery patients is over 70, so one might think this is not the internet generation; yet there is also some evidence that patients’ families investigate performance data on their behalf.
Still, it seems peer pressure and professional prestige are the primary drivers in explaining improved mortality rates, whether the data is public or confidential. In some areas of surgery, patient choice is misleading since it is a tertiary service requiring referral from another physician. Increasingly, others such as cardiologists are able to prevent the need for surgery. The number of cardiac surgical patients has been falling in most countries for some time.
The Panopticon effect
Public reporting is a dynamic picture, reflecting the actions and reactions of patients, surgeons, managers and the government. The purpose of public reporting is also in transition. The boundary between its educational role (the teacher) and a regulatory (the police officer) role seems to be shifting towards the latter. In either case, public reporting may still follow Jeremy Bentham’s dictum: “the more we are watched, the better we behave”. While this is positive, it can also have some unintended consequences.
Jonathan Gabe is professor of sociology and Mark Exworthy is professor of health policy and management at Royal Holloway University of London, M.Exworthy@rhul.ac.uk; Ian Rees Jones is professor of sociological research at Cardiff University