Using Confidential Clinical Data Registries for Public Reporting and Pay for Performance

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In the early 20th century, Dr Ernest Codman introduced the concept of enhancing the quality of medical care by measuring outcomes data to target areas for improvement.1 He was shunned by his peers at the time, but would be pleased to know that his vision has lived on in the modern healthcare system in the United States. Reporting of quality data is now intimately tied to reimbursement for hospitals across the United States, and as a result, quality improvement (QI) activities centered on processes of care and patient outcomes data are ubiquitous. Much QI activity is carried out with the help of confidential clinical registry data, through which performance deficiencies are identified by either comparing outcomes internally over time, or benchmarking across institutions in a deidentified manner to not distract from the end goal of QI. Data allow clinicians to improve care through the identification of problem areas, the institution of best practices that target problem areas, and a continuous cycle of feedback on best practices. QI based on confidential registry data has patient care at the heart of its mission, with punitive actions being the exception rather than the rule, consistent with a culture of safety. While public reporting and payment informed by performance measures have the potential to improve quality, the use of clinical registry data for these purposes risks undermining the integrity of these registry programs by essentially incentivizing risk aversion and fraudulent data collection.
The American College of Surgeons, National Surgical Quality Improvement Program (ACS NSQIP) is an example of a confidential clinical data registry, and is utilized in more than 600 hospitals across the United States. ACS NSQIP uses trained and data coordinators to collect more than 200 high-quality clinical variables per case, based on rigorous specifications, maintaining superior validity in capturing outcomes when compared with administrative databases.2 Data are fed back to each individual hospital through risk-adjusted and non-risk-adjusted reports on 14 universal outcomes (ie, 30-day mortality, surgical site infection), and many other operation-specific outcomes, allowing for internal, and also multi-institutional benchmarking. Hospitals enrolled in ACS NSQIP have demonstrated improvement in clinical outcomes over time, potentially increasing in magnitude with length of time in the program.3 There are many other validated clinical registries within the surgical realm that contribute significantly to QI, one of them being The Society of Thoracic Surgeons National Database. This confidential clinical registry provides validated, robust, risk-adjusted data that are used to advance patient outcomes in adult cardiac, congenital cardiac, and general thoracic surgery through clinical research and National Quality Forum (NQF)-endorsed quality measures.4
Health plans, including those of the government, currently use administrative claims data to monitor provider performance and to benchmark providers against competitors. Recently, payers have begun to create incentives for, or to mandate altogether, hospitals to submit performance results from confidential clinical data registries such as the ACS NSQIP. Payers are using, or are anticipated to eventually use, these results to implement their own pay for performance (P4P) protocols.
Public reporting of patient outcomes data has become more common, with the laudable goals of increasing transparency and improving patient awareness. Driven in part by federal mandates from the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) have made patient outcomes data available for public consumption from over 4000 Medicare-certified hospitals through hospital ranking efforts such as Hospital Compare.
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