Information and transparency – the keys to sustainable changes in the Swiss healthcare system

Highly intensive discussions on the reform of our healthcare system are taking place everywhere. Although many of the parties involved agree that our health system is about to undergo a far-reaching transformation – with the critical driving forces being technological, demographic and economic changes – there is hardly any consensus as to how these changes in our healthcare system should transpire. The underlying motives of the criticisms to proposals for improvement are often not clear.

The same can be said when dealing with the issues of transparency and information in healthcare. All the exponents, without exception, recognise that greater transparency and better information regarding the quality of services provided would be valuable, and healthcare systems are no exception from this rule. However, the creation of transparency and clear information is slowed down and hindered, among other things, by data protection arguments and the idea of shielding consumers/patients from confusion in their decision-making process. The impact has been that, up until now, in Switzerland even the most basic data can only be obtained from hospitals and doctors at considerable effort.

Data on the quality of treatment: recommendation for a three-stage procedure

The public is showing an increasing interest for information on the quality of treatment provided by medical institutions. When requiring medical care, patients should be able to compare the quality of medical services offered by various hospitals and choose a hospital with the demonstrably highest level of patient care. Politicians are, therefore, demanding that hospitals and, before long, all practising doctors have to measure the quality of their care and make it publicly accessible. According to statements made by Dr. Markus Dürr, President of the Canton Health Director Conference, all Swiss hospitals should publish such quality data within the next two to three years and make it available for the public.

There are numerous discussions occurring on the sidelines as to whether or not, and how, it would be possible to actually determine quality in the medical field. Hence, the reactions to the study published by Comparis on patient satisfaction, unplanned readmissions to hospitals and treatment errors in hospitals have been diverse, if not harsh. H+, the Union of Swiss Hospitals, wants to voluntarily publish their figures on the treatment quality of its hospitals. In doing this, the basis for reaching a decision by the population currently would not be easier, since the quantification of the quality of treatment and the interpretation of the results are clearly very complex topics. Nonetheless, as a principal agreement has been reached on providing information on the quality of treatment, we suggest a three-stage procedure for making this information available to the general public; we will explain the reasons for this approach in the following paragraphs.

1. In the first phase, all information on the number of diagnostic and therapeutic procedures should be published.
2. In the second phase, the concepts and methods for measuring the quality of treatment should be developed or refined.
3. Only in the third phase, when robust and non-ambiguous results are available, should these be made accessible to everybody.

Stage 1:  Publication of case figures
Information on the number of diagnostic examinations carried out each year, for example, cardiac catheter examinations, angiograms of brain vessels, and therapeutic operations, such as, radical prostate removals, operations on the liver, or heart valve operations, do not constitute actual information on the quality of treatment. Such information does, however, reveal certain conclusions on the competence and experience of a given provider. Studies analysing the correlation between the number of diagnostic/therapeutic operations and their outcomes, demonstrate that a certain number of interventions are necessary in order to achieve the required level of quality. If a patient knows, for example, that in one hospital two liver operations are carried out per year while in another there are fifty, the patient can interpret the data for his or herself and decide which hospital to choose for their operation. The patient can assume responsibility and weigh up the various  factors as part of his decision-making process – just as he currently and successfully does as a mature consumer.

Stage 2:  Quantification and interpretation of the quality of treatment
Discussions on the definition of the phrase, quality of treatment,have not as yet reached a consensus. This explains to a degree the problems arising when “measuring” the quality of medical treatment. In principle, there are various methods for quantifying the quality of a given treatment. One method is the so-called “standards of care” formula. Prescribing aspirin to patients with acute myocardial infarction is such a standard. It is relatively straightforward to measure whether this requirement is fulfilled or not and the results of the measurement are thus easy to interpret. If the standard, however, requires that the target for hypertensive patients is to have a blood pressure of less than 140/90 mm Hg, then it will be harder to achieve. Anti-hypertensive medication has side effects and the advantages of reaching treatment goals have to be balanced. If defined “standards of care” do not exist or alternatively, they are not clearly definable, “quality indicators” have to be established. Mortality rates after intervention and complication rates are examples of quality indicators. Hospitals or doctors should be compared on the basis on these indicators. In any case, it is clear that either legal guidelines are needed in order to publish such indicators, or there has to be a broad and graded consensus on what constitutes an indicator. Otherwise, we will witness the same phenomena which followed the publication of a patient satisfaction survey of hospital patients by Comparis; the results were questioned by the hospital union H+ who published their own figures utilising different standards.

A problem that has not yet been satisfactorily resolved during this exchange of ideas is the ability of patients to compare different hospitals. With a statistical procedure, an attempt is made to enable a patient to compare hospitals. The problem is, however, that in these statistical model calculations, it has only been possible to take into consideration the factors that are known to have an influence on the outcome, for example, the mortality or complication rates. Other, as yet unknown factors, which are difficult to record, have not yet been taken into account in the statistical models. There are, at the moment, few methods, which have been validated to balance the differences of patient characteristics and therefore facilitate the attainment of sound results. Despite these shortcomings, this data should be gathered and made available to the relevant institutions. This has been carried out since many years by the Outcome association. As a result, hospitals have the possibility to interpret their data by themselves and should be obliged to deduce the consequences.

Publishing this data may be politically desirable, but the undesirable consequences of taking such action must also be examined carefully when the quality of a hospital or doctor is assessed publicly or by cost bearers. Patients with a high risk of complications would be moved from one hospital to another and thus not receive the correct treatment; studies in the U.S. clearly show this to be the case. An example, which illustrates this point, concerns patients with coronary artery disease. All experienced cardiologists know that a catheter-based reopening of the coronary arteries in patients with acute infarct and additional shock markedly improves the survival of such patients when taken as a whole. The cardiologist also knows that the complication rate of these patients is higher. Taking this into account, if the quality of a hospital or doctor is assessed publicly or by cost bearers and is based on the complication rate, it may well be that patients with an expected high complication rate will be made to use the services of an inappropriate hospital and a necessary operation will not be carried out.

Stage 3:  Publication of sound and interpretable quality data
Reservations on publishing the results of the quality of medical treatment are due to the associated problems involved in choosing a method that can adequately measure quality. If the problems involved with choosing a quality standard are solved and the performance results of individual hospitals or doctors can therefore be interpreted, this data must be published and made available to the general public. Only then, can the proposed reforms, such as having the freedom to choose a hospital or the introduction of electronic health record systems ensure that the full effect on the improvement of quality and costs in the healthcare system actually comes to fruition.

Authors
Prof. Dr. med. Johann Steurer manages the Horten Zentrum for practice oriented research and knowledge transfer at the University of Zurich
Dr. Urs Läubli is a partner of Hirzel.Neef.Schmid Counsellors, communication and business consultants in Zurich and Bern
Prof. Jakob Nüesch, is a microbiologist, former President of ETH Zurich
Dr. med. Hans Groth is a member of the Board of Directors, Pfizer Switzerland AG

Further literature
Porter M.E., Teisberg E. O., Redefining Health Care: Creating Value-Based Competition on Results.  Harvard Business School Publishing. 2006

Mason A., Street A. Publishing outcome data: is it an effective approach? Journal Eval Clin Pract. 2006; 12: 37-48.

Lee T.H., Torchiana D.F., Lock J.E. Is zero the ideal death rate? N Engl J Med. 2007; 357: 111-113.

Omoigui N.A., Miller D.P., Brown K.J., Annan K., Cosgrove D., Lytle B., Loop F., Topol E.J. Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes. Circulation 1996; 93: 27-33.