Wednesday, 13 August 2008

Health league tables - pros and cons

Another interesting bit from my latest read. In 1989 the New York State Department of Health initiated a programme to improve the quality of care for coronary artery bypass graft (CABG) surgery by applying market forces. Basically they started providing hospital- and surgeon-specific performance figures. The idea being that punters would respond by avoiding the poor providers of care, thus providing a market discipline.

Two things happened - mortality rates associated with CABG fell, a good thing. But conversely there was no significant shift in patient demand - the punters didn't move from high-risk hospitals to low-risk ones, even when public awareness of the available mortality data was high.

A few things might be going on here. For example, maybe patients are wary of making a choice for themselves (because it's a high stakes choice) and hence are instead relying on personal recommendations from friends and family. So people stick with hospitals they know and like, regardless of data. Another interpretation is that the publication of data made surgeons more risk averse. They might not want to take on high-risk patients if it knackered their batting average. So apparently improved mortality data might tell a different story.

Notably however research found that one in five doctors with bottom quartile performance ended up leaving cardiac surgery, which suggests that maybe there was a bit of a 'punishment' effect, even if it wasn't the result of punter pressure.


Nick Drew said...

in this instance, is the customer in fact the insurance co ? (contributing rather more knowledgeably & dispassionately to a 'punishment effect' than patients would ?)

Tom P said...

yes it might be, although it doesn't mention it in the paper. I'll have a look and see if there are any further details in the references