Time for Transparent Standards in Quality Reporting

Posted by

A recent issue of JAMA contained a Viewpoint article by Pronovost and colleagues about the need for transparent standards in quality reporting by healthcare organizations:.

I communicated with Pronovost to thank him for raising this issue. I’ve been troubled about this for more than a decade and it’s the reason we recently published the article about “Fantasy Healing Rates.” We demonstrated that the average healing rate reported by wound centers (based on a methodical sample of the internet) was >92%, even though it is impossible for this to be true. The JAMA article points out that lack of data transparency is not an issue that is limited to the field of wound care. A conflict of interest exists whenever healthcare organizations report their own data. Although hospitals and physicians are perceived as trusted entities, as pointed out by Pronovost, “these organizations have an incentive to present themselves in a positive light.” Potentially misleading information is being provided to the public on issues such as infection rates, with one hospital stating on its website, “Come to us, we have no infections,” without stating which types of infections were included, how this performance outcome was measured, or how long the hospital had gone without an infection.

There are no standards to guide the public reporting of data by hospitals and physicians. To make matters worse, many times these efforts are led by the marketing department, and there may even be incentives NOT to be truthful. I was in the audience when the Chief Executive Officer of a hospital system with which I had been affiliated for many years accepted a highly coveted national safety award and gave a moving speech about how his large hospital system achieved a rate of zero adverse events. I was surprised to see him up there on the podium, because I personally knew of at least 2 adverse events in my hospital alone which was one of 5 in the system. In one of those strange coincidences of life, about 6 months later I was seated next to a young woman at a dinner party who told me she quit her very first job at the corporate headquarters of that hospital system. She was devastated because she had been told to falsify safety reports and being too honorable to do that, she quit her very first job. I was mystified by this event until a Google search revealed that the monetary value of the CEO’s retirement package was tied to the hospital’s safety rating. The dollar figure involved was large.  Medicare’s Quality Payment Program seeks to align compensation with outcomes. It’s fair to say that the system we currently have in which compensation is completely divorced from either outcome or value is bankrupting Medicare and doesn’t foster good patient care. However, a system that ties compensation to outcome will only going to work if we have transparency in reporting.

A recently published article in Wound Repair and Regeneration determined that the Healogics wound healing rate is 75% (rather than the 92% on program websites). Frustratingly, the paper did not describe which patients were excluded from the denominator. I’m afraid the effort we put into the paper establishing standards for registry reporting in wound care (also published in WWR, in April) was wasted. It’s an example of why reporting wound healing by risk category (which is what CMS demands) is still the right way to do it. Reporting by risk category allows you to report practically every patient without being “punished” for having a low healing rate among the very worst cases, because the goal is not to achieve some artificial healing rate overall, but to achieve a better healing rate than predicted for wounds of THAT SEVERITY. Reporting healing by severity (risk category) enables both patients and payers to identify the clinicians who consistently provide the highest quality care. It also enables us to identify the incremental benefit of specific advanced therapeutics.

Bigger datasets are not better if you can’t risk stratify the patients and don’t adhere to standards for registry reporting. The JAMA article suggests some basic standards for hospitals and physicians when reporting their own quality data. I’ve reproduced the table from the JAMA article. It includes basic information about how the patient population, the measure, and hospital or physician performance are defined. I’ve also included the table from our WWR paper that details the standards for reporting registry data for use in wound care research. Lack of transparency in outcomes reporting is not limited to the field of wound care. We are going to have to fix this problem. Join me in reporting Honest Healing Rates.

https://jamanetwork.com/journals/jama/fullarticle/2648006

JAMA.  2017;318(8):701-702.

Fife CE, Eckert KA. Harnessing Electronic Healthcare Data for Wound Care Research: Standards for Reporting Observational Registry Data Obtained Directly from Electronic Health Records. Wound Repair Regen. 2017 Apr 1. doi: 10.1111/wrr.12523