1 in 4 Ontario hospitals change cardiac care policies after public report cards released

Public report cards on hospital performance are increasingly common, but researchers at the Institute for Clinical Evaluative Sciences (ICES) wanted to find out whether they are an effective method for improving the quality of cardiac care for patients.

In the first randomized controlled trial of public report cards, ICES researchers studied whether the quality of cardiac care improved when 81 Ontario hospital corporations were split into two groups: 42 received early publication of a public report card containing information on their baseline performance (between April 1999 to March 2001) on a set of 18 national process of care quality indicators, while 39 received delayed publication of the same information.

Most AMI (heart attack) and CHF (heart failure) process of care (e.g., drug treatments and diagnostic tests) indicators improved over time, with a similar rate of improvement in the overall quality indicators in both groups of hospitals.

Greater improvements were noted in the early report card hospitals for two treatment indicators and mortality rates were lower in heart attack patients being cared for in these hospitals than in hospitals that received the delayed report cards.

Key findings include:

• 10 out of 42 hospitals (24 per cent) in the early feedback group vs. two out of 39 hospitals in the delayed feedback group reported changing their policies to allow emergency room physicians to give patients ‘clot-busting’ drugs for heart attack patients rather than waiting for a specialist consultation.
• A significantly higher proportion of patients (96 per cent vs. 92 per cent) in the early feedback hospital arm had ‘clot-busting’ drugs given to them in the emergency room before transfer to a CCU/ICU.
• There was significantly higher use of medications called ACE inhibitors and angiotensin receptor blockers (ARBs) (92 per cent vs. 86 per cent) in heart failure patients in early feedback hospitals, in the year after publication of the early feedback report cards.
• Hospitals in the early feedback arm were significantly more likely (73 per cent vs. 47 per cent) to report undertaking quality improvement activities to improve heart attack care than hospitals in the delayed feedback arm.
• In the follow-up period, the average 30-day hospital AMI mortality rates were 2.5 per cent lower in the early feedback hospital arm as compared with the delayed feedback hospital arm, after adjusting for baseline hospital outcomes. CHF mortality rates were not significantly different.

“An interesting finding from our study was the observation that 30-day heart attack mortality rates were lower in the patients treated at the early feedback hospitals. While we cannot be certain as to whether this finding was due to the report cards or due to other unknown factors, we believe the EFFECT study data likely stimulated some important local hospital-specific changes in delivery of care that may have contributed to the better outcomes observed at early feedback hospitals,” says Dr. Tu, lead researcher and senior scientist at ICES.

"Canada is known to provide some of the best healthcare in the world," says Dr. Peter Liu, Scientific Director at the Canadian Institutes of Health Research's Institute of Circulatory and Respiratory Health. "The Canadian Cardiovascular Outcomes Research Team (CCORT’s) EFFECT study funded by our Institute has helped us do even better. A strategy of giving public feedback to the healthcare system on its performance stimulated many quality improvement initiatives. This was associated with fewer heart related deaths. This study's key findings help us identify the best methods to provide quality cardiac care and to put patient's needs first, which is our main priority."

The study “Effectiveness of public report cards for improving the quality of cardiac care: The Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study” is in the November 18, 2009 online issue of JAMA.

CCORT web site: www.ccort.ca/EFFECTStudy.aspx

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

Dr. Tu is supported by a Tier 1 Canada Research Chair in Health Services Research and a Career Investigator Award from the Heart and Stroke Foundation of Ontario. He is an attending staff cardiologist at the Schulich Heart Centre, Sunnybrook Health Sciences Centre, and a Professor of Medicine at the University of Toronto. The EFFECT study was funded a Canadian Institutes of Health Research (CIHR) Team Grant in Cardiovascular Outcomes Research to the Canadian Cardiovascular Outcomes Research Team (CCORT) and the Heart and Stroke Foundation of Canada.

FOR FURTHER INFORMATION PLEASE CONTACT:

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