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      Public reporting in health care: how do consumers use quality-of-care information? A systematic review.

      Medical Care
      Choice Behavior, Consumer Behavior, statistics & numerical data, Health Knowledge, Attitudes, Practice, Health Services Research, Humans, Information Dissemination, Information Services, classification, utilization, Outcome and Process Assessment (Health Care), Patient Acceptance of Health Care, Peer Review, Health Care, Quality Indicators, Health Care, Randomized Controlled Trials as Topic, United States

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          Abstract

          One of the underlying goals of public reporting is to encourage the consumer to select health care providers or health plans that offer comparatively better quality-of-care. To review the weight consumers give to quality-of-care information in the process of choice, to summarize the effect of presentation formats, and to examine the impact of quality information on consumers' choice behavior. The evidence is organized in a theoretical consumer choice model. English language literature was searched in PubMed, the Cochrane Clinical Trial, and the EPOC Databases (January 1990-January 2008). Study selection was limited to randomized controlled trails, controlled before-after trials or interrupted time series. Included interventions focused on choice behavior of consumers in health care settings. Outcome measures referred to one of the steps in a consumer choice model. The quality of the study design was rated, and studies with low quality ratings were excluded. All 14 included studies examine quality information, usually CAHPS, with respect to its impact on the consumer's choice of health plans. Easy-to-read presentation formats and explanatory messages improve knowledge about and attitude towards the use of quality information; however, the weight given to quality information depends on other features, including free provider choice and costs. In real-world settings, having seen quality information is a strong determinant for choosing higher quality-rated health plans. This review contributes to an understanding of consumer choice behavior in health care settings. The small number of included studies limits the strength of our conclusions.

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          Who is at greatest risk for receiving poor-quality health care?

          American adults frequently do not receive recommended health care. The extent to which the quality of health care varies among sociodemographic groups is unknown. We used data from medical records and telephone interviews of a random sample of people living in 12 communities to assess the quality of care received by those who had made at least one visit to a health care provider during the previous two years. We constructed aggregate scores from 439 indicators of the quality of care for 30 chronic and acute conditions and for disease prevention. We estimated the rates at which members of different sociodemographic subgroups received recommended care, with adjustment for the number of chronic and acute conditions, use of health care services, and other sociodemographic characteristics. Overall, participants received 54.9 percent of recommended care. Even after adjustment, there was only moderate variation in quality-of-care scores among sociodemographic subgroups. Women had higher overall scores than men (56.6 percent vs. 52.3 percent, P<0.001), and participants below the age of 31 years had higher scores than those over the age of 64 years (57.5 percent vs. 52.1 percent, P<0.001). Blacks (57.6 percent) and Hispanics (57.5 percent) had slightly higher scores than whites (54.1 percent, P<0.001 for both comparisons). Those with annual household incomes over 50,000 dollars had higher scores than those with incomes of less than 15,000 dollars (56.6 percent vs. 53.1 percent, P<0.001). The differences among sociodemographic subgroups in the observed quality of health care are small in comparison with the gap for each subgroup between observed and desirable quality of health care. Quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care. Copyright 2006 Massachusetts Medical Society.
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            The unintended consequences of publicly reporting quality information.

            Health care report cards publicly report information about physician, hospital, and health plan quality in an attempt to improve that quality. Reporting quality information publicly is presumed to motivate quality improvement through 2 main mechanisms. First, public quality information allows patients, referring physicians, and health care purchasers to preferentially select high-quality physicians. Second, public report cards may motivate physicians to compete on quality and, by providing feedback and by identifying areas for quality improvement initiatives, help physicians to do so. Despite these plausible mechanisms of quality improvement, the value of publicly reporting quality information is largely undemonstrated and public reporting may have unintended and negative consequences on health care. These unintended consequences include causing physicians to avoid sick patients in an attempt to improve their quality ranking, encouraging physicians to achieve "target rates" for health care interventions even when it may be inappropriate among some patients, and discounting patient preferences and clinical judgment. Public reporting of quality information promotes a spirit of openness that may be valuable for enhancing trust of the health professions, but its ability to improve health remains undemonstrated, and public reporting may inadvertently reduce, rather than improve, quality. Given these limitations, it may be necessary to reassess the role of public quality reporting in quality improvement.
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              Hospital performance reports: impact on quality, market share, and reputation.

              This study builds on earlier work by assessing the long-term impact of a public hospital performance report on both consumers and hospitals. In doing so, we shed light on the relative importance of alternative assumptions about what stimulates quality improvements. The findings indicate that making performance data public results in improvements in the clinical area reported upon. An earlier investigation indicated that hospitals included in the public report believed that the report would affect their public image. Indeed, consumer surveys suggest that inclusion did affect hospitals' reputations.
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