Cardiac surgery report cards: comprehensive review and statistical critique

Area of Science:

• Cardiovascular Surgery
• Health Services Research
• Biostatistics

Background:

• Public report cards and confidential, collaborative peer education are distinct methods for cardiac surgery quality assessment.
• Report cards, often state-mandated, assume public disclosure motivates providers and market forces reward quality, but evidence is mixed.
• Nationwide declines in heart surgery mortality and hospital-developed internal quality programs confound the impact of report cards.

Purpose of the Study:

• To review the controversies surrounding the methodology and effectiveness of public report cards versus collaborative peer education for cardiac surgery quality.
• To identify potential negative consequences of report cards, such as high-risk case avoidance and "gaming" the system.
• To advocate for improved statistical methods and the integration of continuous quality improvement with any public reporting.

Main Methods:

• Review of existing literature on cardiac surgery quality assessment and improvement strategies.
• Discussion of the statistical methodologies underlying public report cards and their limitations.
• Comparison of the effectiveness and potential drawbacks of public report cards and continuous quality improvement (CQI) programs.

Main Results:

• The effectiveness of public report cards in motivating providers and improving quality is challenged by numerous studies.
• Report cards may lead to negative behaviors like high-risk case avoidance and system gaming.
• Continuous quality improvement programs show effectiveness in improving performance and reducing variability but lack public accountability.
• Current statistical methodologies for report cards are flawed, with inherent imprecision in risk-adjustment models.

Conclusions:

• Public report cards' impact on cardiac surgery mortality is unclear and may be confounded by other factors.
• Collaborative, confidential continuous quality improvement programs offer advantages but do not ensure public accountability.
• Improved statistical techniques, such as hierarchical models, and emphasis on statistical uncertainty are crucial for accurate public reporting.
• A combination of appropriate statistical methods for public reporting and simultaneous implementation of CQI programs is recommended.