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A recent initiative to publish the mortality rates of Ohio hospitals did not reduce the market share of hospitals with worse than expected mortality rates (given the procedure and patient risk factors) or improve patient outcomes. The Cleveland Health Quality Choice (CHQC) program identified several hospitals as having significantly higher than expected mortality rates, longer than expected length of hospital stay, and worse patient satisfaction. Yet, none of these hospitals lost contracts because of their poor performance.
As shown in other studies, for value based purchasing to work, purchasers need to resist community pressures to ensure there will be no "losers." Changes in market share may need to be seen as a real possibility before intensive efforts to improve hospital performance begin in earnest, concludes David W. Baker, M.D., M.P.H., of Feinberg School of Medicine, Northwestern University.
In the study supported by the Agency for Healthcare Research and Quality (HS09969), Dr. Baker and his colleagues examined market share and mortality rates for six medical conditions (adjusted for patient mortality risk factors) from 1991 to 1997 for all 30 non-Federal hospitals in Northeast Ohio. The conditions included heart attack, heart failure, gastrointestinal hemorrhage, obstructive pulmonary disease, pneumonia, and stroke. The five hospitals with the highest mortality rates tended to lose market share, but the loss was not significant (mean change of -0.6 percent).
With one exception, risk-adjusted mortality declined only slightly at hospitals classified as "below average" (-0.8 percent) or "worst" (outliers, -0.4 percent). The failure of the CHQC program to affect patient outcomes or market share of poor performing hospitals may have resulted from consumer disinterest or difficulty in interpreting complex CHQC reports. Or it could have been due to unwillingness of businesses to create incentives targeted to hospitals' performance and hospitals' inability to develop effective quality improvement programs. On the other hand, even when consumers understand which hospitals have higher mortality rates, conditions like stroke or heart attack represent emergencies that prompt them to go to the nearest hospital, mortality rates notwithstanding.
See "The effect of publicly reporting hospital performance on market share and risk-adjusted mortality at high-mortality hospitals," by Dr. Baker, Doug Einstadter, M.D., M.P.H., Charles Thomas, M.S., and others, in the June 2003 Medical Care 41(6), pp. 729-740.
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