Consumer Guides Are Found to Improve Health Care

Consumer guides--those “report cards” that rate hospitals, health plans, doctors and other medical services--have become road maps for millions of Americans trying to navigate today’s increasingly complicated health care maze.

Now a team of Missouri researchers has documented an unexpected benefit from these guides: a significant improvement in the quality of care and range of services offered in hospitals that are publicly rated.

The study focused on obstetric services in more than 80 hospitals throughout the state. In 1993, the Missouri Department of Health rated these services and released the results to the public. Within a year of the report, researchers found that expectant mothers received more services overall and had a better chance of getting through childbirth without complications than before the consumer guide was published.

Hospitals, for example, reduced the number of Caesarean-section deliveries and increased the number of subsequent vaginal births after Caesareans. They also increased the number of transfers of high-risk infants to hospitals with specialized facilities and reported a greater use of ultrasound diagnostic tests and monitoring. Approximately one-third of the hospitals that did not have nurses to show new mothers how to breast-feed instituted lactation-education programs after the report was published.

“Public release of consumer reports may be useful not only in assisting consumers to make informed health care choices, but also in facilitating improvement in the quality of hospital services and care provided,” concluded researchers from the University of Missouri, Columbia, and the Missouri Department of Health.

The impact was greatest for hospitals located in areas where there was competition for patients among hospitals and other medical facilities, according to the study.

“Hospitals in competitive markets were found to be about twice as likely to consider improving,” the researchers noted in a special issue of the Journal of the American Medical Association dedicated to questions about quality of care. “Thus, knowledge of competitor services may play a large role in a hospital’s decision to provide certain services.”

“The study confirmed that if doctors or hospitals were given objective data (showing their practices could be improved), they would make the needed changes,” said Daniel R. Longo, the lead author of the study.

Before joining the faculty of the University of Missouri, Columbia, School of Medicine, Longo spent 20 years specializing in problems of quality assurance with the Joint Commission on the Accreditation of Hospitals, the American Hospital Association and the Hospital Association of New York.

“I’ve been on both sides of the fence,” said Longo, “and I know that there is something about public disclosure that makes a difference. Public reports are in the public interest. We have not seen many changes in the quality of care without public accountability.”

Hospitals, especially those that scored no better than average in patient-satisfaction ratings in the initial survey, added nonmedical services to improve their scores in future surveys, according to the researchers. For example, 18 hospitals instituted new rules that all infants must go home in a car seat.

What’s more, hospitals whose charges were higher than average were “more likely than other facilities to at least be discussing the appropriateness of their charges,” the researchers reported.

Consumer guides are a new wrinkle in attempts to increase the quality of care. They include basic information on the services offered at different hospitals as well as surveys on patient satisfaction.

While the first public report on health care quality was Florence Nightingale’s 19th century publication of mortality rates in London hospitals, the medical community has generally resisted a scorecard approach to patient care.

Organizations representing doctors and hospitals have fought most attempts by government agencies and consumer groups to make such information public. Their position is that raw data on individual hospitals and doctors are too complicated for the public to understand and would lead to misunderstandings that could hurt medical professionals and institutions.

Even now, the American Medical Association has succeeded in keeping the public from gaining access to a federal register of doctors who have faced disciplinary proceedings or been accused in civil malpractice suits.

But the notion of public accountability has gained credence in recent years. According to the Missouri researchers, the first reference to consumer reports on health care surfaced about 15 years ago. Since then these reports have proliferated as managed-care plans seek ways to evaluate medical treatment for their members.

In California, alone, there have been 22 statewide reports, three metropolitan area reports, seven corporate and two national efforts to monitor quality of care, according to a 1994 survey.

One of the most successful consumer guides is the New York State Department of Health review of death rates in open-heart surgery. These reports, which list the death rates of doctors and hospitals by name, have led to reforms in the medical community. In five years, the state has seen a 52 percent decline in heart-surgery mortality rates.