Schneider E C, Epstein A M
Section on Health Services and Policy Research, Brigham and Women's Hospital, Boston, MA, USA.
N Engl J Med. 1996 Jul 25;335(4):251-6. doi: 10.1056/NEJM199607253350406.
Reports on the comparative performance of physicians are becoming increasingly common. Little is known, however, about the credibility of these reports with target audiences or their influence on the delivery of medical services.
Since 1992, Pennsylvania has published the Consumer Guide to Coronary Artery Bypass Graft Surgery, which lists annual risk-adjusted mortality rates for all hospitals and surgeons providing such surgery in the state. In 1995, we surveyed a randomly selected sample of 50 percent of Pennsylvania cardiologists and cardiac surgeons to find out whether they were aware of the guide and, if so, to determine their views on its usefulness, limitations, and influence on providers.
Eighty-two percent of the cardiologists and all the cardiac surgeons were aware of the guide. Only 10 percent of these respondents reported that its mortality rates were "very important" in assessing the performance of a cardiothoracic surgeon. Less than 10 percent reported discussing the guide with more than 10 percent of their patients who were candidates for a coronary-artery bypass graft (CABG). Eighty-seven percent of the cardiologists reported that the guide had a minimal influence or none on their referral recommendations. For both groups, the most important limitations of the guide were the absence of indicators of quality other than mortality (cited by 78 percent), inadequate risk adjustment (79 percent), and the unreliability of data provided by hospitals and surgeons (53 percent). Fifty-nine percent of the cardiologists reported increased difficulty in finding surgeons willing to perform CABG surgery in severely ill patients who required it, and 63 percent of the cardiac surgeons reported that they were less willing to operate on such patients.
The Consumer Guide to Coronary Artery Bypass Graft Surgery has limited credibility among cardiovascular specialists. It has little influence on referral recommendations and may introduce a barrier to care for severely ill patients. If publicly released performance reports are intended to guide the choice of providers without impeding access to medical care, a collaborative process involving physicians may enhance the credibility and usefulness of the reports.
关于医生比较表现的报告日益普遍。然而，对于这些报告在目标受众中的可信度及其对医疗服务提供的影响，人们了解甚少。
自1992年以来，宾夕法尼亚州发布了《冠状动脉搭桥手术消费者指南》，该指南列出了该州所有提供此类手术的医院和外科医生的年度风险调整死亡率。1995年，我们对随机抽取的50%的宾夕法尼亚州心脏病专家和心脏外科医生进行了调查，以了解他们是否知晓该指南，如果知晓，则确定他们对其有用性、局限性以及对医疗服务提供者的影响的看法。
82%的心脏病专家和所有心脏外科医生知晓该指南。这些受访者中只有10%报告称其死亡率在评估心胸外科医生的表现时“非常重要”。不到10%的受访者报告称，他们与超过10%的冠状动脉搭桥手术（CABG）候选患者讨论过该指南。87%的心脏病专家报告称该指南对他们的转诊建议影响极小或没有影响。对于这两组人来说，该指南最重要的局限性是缺乏除死亡率之外的质量指标（78%的人提到）、风险调整不足（79%）以及医院和外科医生提供的数据不可靠（53%）。59%的心脏病专家报告称，为病情严重且需要CABG手术的患者寻找愿意进行手术的外科医生变得更加困难，63%的心脏外科医生报告称他们不太愿意为这类患者做手术。
《冠状动脉搭桥手术消费者指南》在心血管专家中的可信度有限。它对转诊建议影响甚微，可能会给重症患者的治疗带来障碍。如果公开发布的表现报告旨在指导医疗服务提供者的选择而又不妨碍获得医疗服务，那么一个涉及医生的协作过程可能会提高报告的可信度和有用性。
