Julian Nieves, MD, MPH

Julian Nieves, MD, MPH

2002-2003

Founder and Physician, Salud Primary Care, West Hartford, CT

Dr. Nieves is founder and CEO of Salud Primary Care LLC, specializing in Primary Care Internal Medicine. He received his medical degree from Cornell University Medical College in 1995 and completed residency at the Yale Primary Care Internal Medicine Residency Program in 1998. He has over a decade of extensive inpatient and outpatient clinical experience at institutions including Yale-New Haven Hospital, Hartford Hospital, and Massachusetts General Hospital. His academic duties have also included serving as Clinical Instructor at the Harvard School of Medicine and Assistant Professor at the University of Connecticut School of Medicine.

Dr. Nieves obtained his MPH from the Harvard School of Public Health in 2003 and completed a fellowship at the Commonwealth Fund/Harvard University Minority Health Policy Program where he furthered his interest in the issues of health care quality outcomes, preventive care, and primary care redesign strategies. He has practiced as a primary care physician serving the Hartford community and as part of Internal Medicine Associates at Massachusetts General Hospital in Boston. He was also Medical Director for inpatient Hospitalist Services at Mid-State Medical Center in Meriden, CT, and founder of the Connecticut Chapter for the Society of Hospital Medicine.

The Effectiveness of Comparative Public Reporting on Hospital Quality Performance: An Environmental Scan of the Evidence

Background:

Public information about the performance of hospitals, health professionals, and health care organizations has increased substantially in recent years, and has become one of the most visible efforts in the quest to manage the quality of health care delivered in the United States. The proliferation and acceptance of clinical practice measures has facilitated the development of quality indicators, and the computerization of medical data has made it easier than ever before to measure quality of care. The internet also promises to make data dissemination easier and more accessible than ever before.  Large-scale purchasers of health care services have driven the process of public quality reporting, but state and federal health agencies along with traditional accrediting bodies are also beginning to require that health care providers furnish performance data for public use.  The development of effective comparative hospital quality reporting systems has quickly become a key policy issue with the potential to influence many national debates.  The complexity of the task, potential high costs, and considerable concern over ineffective systems make it pertinent to ask the question: “Does comparative public reporting of hospital quality performance change hospital provider decision-making behavior?”.

Methods:

An extensive review of published articles in peer review journals was conducted using MEDLINE and PubMed electronic databases. Review was limited to U.S. reports between 1995 and 2003. Searches were conducted using the following Medical Headings: Quality Assurance Health Care, Quality Control, Health Policy, Quality Indicators Health Care, Total Quality Management, Legislation and Jurisprudence, Report Cards, Public Performance Reports, and Disclosure.  Key informant interviews were also conducted with information placed in context with the literature review.  The interviewees were selected to represent a range of stakeholders and comprise leading academics with an active research interest in the topic, senior staff of federal and state government departments, senior staff from public and private quality oversight organizations, and hospital provider groups.

Results:

There is some evidence that provider organizations and hospitals are more responsive to performance data than consumers, purchasers or individual physicians. Evidence suggests that making performance information public stimulates quality improvement in areas reported to be low.  Findings also indicate that hospitals, as a result of public comparative reports, are addressing issues of health care quality that might have been ignored in the past.  However, generating comparative public quality reports may also generate negative attitudes and distrust among the hospitals included in such reports.

Conclusion:

Comparative public quality reports appear to stimulate institutional providers into action. This may be more due to public image concerns versus potential effects on market share. The very act of collection and dissemination of quality data can cause a hospital to undergo a cultural shift toward putting quality issues at the forefront. However there are still major concerns including data measurability, interpretation, and standardization. Also, there is evidence that making performance data public can result in inappropriate focus on what is being measured and the potential negative impact on the public trust for poor performers should not be discounted.  Also it appears that voluntary reporting efforts are not adequate to ensure widespread quality improvement, with some credence to the development of state mandates for comparative public quality reporting. Finally, not all subgroups are equally well served by the publication of such data, and vulnerable patient groups such as the poor, uninsured, and ethnic/racial minorities may have issues or indicators important to them largely neglected.

Preceptor:

Joxel Garcia, MD, MBA, Commissioner, State of Connecticut Department of Health