Publicly reported provider outcomes: the concerns of cardiac surgeons in a single-payer system

Background — Provider outcomes reports are an important part of quality improvement efforts. The positive and negative impact of such reports on the delivery of care has not been extensively explored.

Methods — A survey of Ontario cardiac surgeons was performed in September 2003 to understand their concerns regarding performance reports. The questionnaire addressed the use of evidence-based practices, the impact of public-provider profiling on clinical practice and the improvement of current report cards. The survey was conducted with the distribution of a fiscal 2000/2001 cardiac surgery report card.

Results — There was a 95% (52 of 55 cardiac surgeons) survey response rate, of which 80% were high-volume surgeons with a case volume of more than 200 cases per year. Seventy-four per cent of surgeons had more than five years of experience. The majority of surgeons believed that performance reports influenced cardiologist referrals (84%) and patient choices (80%). A minority (48%) of surgeons believed that the reporting of inhospital mortality was very or extremely useful, but a majority (83%) believed mortality rates indicated the relative performance of a cardiac surgeon. The majority of surgeons believed that routine upcoding of data (84%) and inadequate risk adjustment (75%) were weaknesses of present performance reports. Surgeons were divided regarding whether the institutional performance should continue to be publicly reported (51% agreed with public reporting).

Conclusions — In a single-payer system, performance reports breed provider concerns similar to those seen in market-driven systems including high-risk patient avoidance and upcoding of data. Regardless, providers recognize that institutional performance reports, irrespective of public or confidential reporting, are important in continuous quality improvement.