Public reporting on quality, waiting times and patient experience in 11 high-income countries

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Health Policy

j o u r n al ho me p ag e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Public reporting on quality, waiting times and patient experience in 11 high-income countries ^夽

Bernd Rechel

, Martin McKee

, Marion Haas

, Gregory P. Marchildon

, Frederic Bousquet

, Miriam Blümel

, Alexander Geissler

,

Ewout van Ginneken

, Toni Ashton

, Ingrid Sperre Saunes

, Anders Anell

, Wilm Quentin

, Richard Saltman

, Steven Culler

, Andrew Barnes

,

Willy Palm

, Ellen Nolte

aEuropeanObservatoryonHealthSystemsandPolicies,LondonSchoolofHygiene&TropicalMedicine,15-17TavistockPlace,London WC1H9SH,UnitedKingdom

bUniversityofTechnologySydney,Australia

cInstituteofHealthPolicy,ManagementandEvaluation,UniversityofToronto,Canada

dCaissenationaledel’assurancemaladiedestravailleurssalaries(CNAMTS),France

eBerlinUniversityofTechnology,Germany

fSchoolofPopulationHealth,UniversityofAuckland,NewZealand

gNorwegianKnowledgeCentrefortheHealthServices(NOKC),Norway

hLundUniversitySchoolofEconomicsandManagement,Sweden

iEmoryUniversity,Atlanta,UnitedStates

jVirginiaCommonwealthUniversity,UnitedStates

kEuropeanObservatoryonHealthSystemsandPolicies,Brussels,Belgium

lEuropeanObservatoryonHealthSystemsandPolicies,LondonSchoolofEconomicsandPoliticalScience,London,UnitedKingdom

a rt i c l e i n f o

Articlehistory:

Received27November2015

Receivedinrevisedform24January2016 Accepted12February2016

Keywords:

Patientsatisfaction Qualityofhealthcare Benchmarking

a b s t ra c t

This article maps current approaches to public reporting on waiting times, patient experienceand aggregatemeasuresofqualityandsafetyin11high-incomecountries (Australia,Canada,England,France,Germany,Netherlands,NewZealand,Norway,Sweden, SwitzerlandandtheUnitedStates).Usingaquestionnaire-basedsurveyofkeynational informants,wefoundthatthedatamostcommonlymadeavailabletothepublicareon waitingtimesforhospitaltreatment,beingreportedformajorhospitalsinsevencountries.

Informationonpatientexperienceathospitallevelisalsomadeavailableinmanycountries, butitisnotgenerallyavailableinrespectofprimarycareservices.Onlyoneofthe11 countries(England)publishescompositemeasuresofoverallqualityandsafetyofcarethat allowtherankingofprovidersofhospitalcare.Similarly,thepublicationofinformation onoutcomesofindividualphysiciansremainsrare.Weconcludethatpublicreportingof

夽 OpenAccessforthisarticleismadepossiblebyacollaborationbetweenHealthPolicyandTheEuropeanObservatoryonHealthSystemsandPolicies.

∗ Correspondingauthor.Tel.:+442079272106;fax:+442079272701.

E-mailaddresses:[email protected](B.Rechel),[email protected](M.Haas),[email protected] (G.P.Marchildon),[email protected](F.Bousquet),[email protected](M.Blümel),[email protected](A.Geissler), [email protected](E.vanGinneken),[email protected](T.Ashton),[email protected](I.S.Saunes), [email protected](A.Anell),[email protected](W.Quentin),[email protected](R.Saltman),[email protected](S.Culler), [email protected](A.Barnes),[email protected](W.Palm),[email protected](E.Nolte).

http://dx.doi.org/10.1016/j.healthpol.2016.02.008

0168-8510/© 2016 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

aggregatemeasuresofqualityandsafety,aswellasofoutcomesofindividualphysicians, remainrelativelyuncommon.Thisislikelytobeduetobothunresolvedmethodologicaland ethicalproblemsandconcernsthatpublicreportingmayleadtounintendedconsequences.

©2016TheAuthors.PublishedbyElsevierIrelandLtd.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Thepublicreportingofthequalityofhealthcareand theperformanceofhealthcareprovidershasexpandedin recentyears,oftenusing dedicatedwebsitestargetedat thegeneralpopulation.Awiderangeofmeasuresisavail- able.Threebroadtypesofinformationcanbedistinguished, relatingto:

•healthcareoutcomes(suchasmortalityratesorratesof complication);

•providerperformance(suchaswaitingtimes,lengthof stayorothercareprocesses);

•patientexperienceandsatisfaction(aselicitedthrough patientsurveys).

Advocates of public reporting believe that it helps to improve transparency and accountability, empowers patientstomakeinformedchoices,andprovidespolicy- makers and third-party payers with the knowledge to informdecisionsonpayment,includingrewardinghighor penalisinglow performers[1,2].Publicreportingofper- formancedataisthoughttoimprovethequalityofcare throughtwoprincipalpathways:thefirst(‘improvement throughselection’) believesthat information onquality providesuserswithknowledgethatwillenablethemto selectprovidersaccordingtoqualitycriteria,whileinthe second(‘improvementthroughchange’),qualityimprove- mentisachievedthroughchangesinproviderbehaviour.

In this latter pathway, information is seen as helping providerstoidentifyareasofunderperformanceandrepor- tingcanact asa stimulusfor improvement, motivating providerstocompeteonquality[3,4].

Publicreportingdoes,however,faceseveralchallenges.

First,publicationcanhaveunintendedconsequences,cre- ating perverseincentives that couldultimately damage quality and public trust. For example, providers may becomemorereluctanttotakeonhigh-riskpatients,clini- calprioritiesmightbecomedistorted,andstaffmoralemay bereduced[3].

Anotherconcernrelatestotheaccuracyoftheinfor- mationusedandtheextenttowhichit reliablyreflects providerperformance[5–7].Theselectionofmeaningful indicatorsisaparticularproblem[2].Theexperienceofthe UnitedStatesisofparticularrelevancehere,asindicators ofproviderperformancehavebeenpublishedforovertwo decades.By2012,theUnitedStatesNationalQualityForum (anon-profitorganisation)hadendorsedmorethan750 measures[2].However,thereislittleoverlapbetweenthe indicatorsusedinvariousprogrammes[8]andastudyof29 privateinsuranceplansidentified550indicators,fewcoin- cidingwiththoseusedinpublicprogrammes[9].Astudy comparingfournationalratingsystemsofhospitalsinthe

UnitedStatesfounddifferentsystemsproducingdifferent results,withonly10%ofthe844hospitalsthatwereranked astopperformersinonesystemdesignatedashighachiev- ersinanyoftheothersystems[10].Althoughthesesystems wereintendedtoinformpatientchoice,thestudyfound that theytendedtoconfuserather thanguideinformed decision-making[10].Indeed,despite20yearsofcompar- isonsofhospitalqualityintheUnitedStates,consumers takesuchinformationintoaccountonlytoasmallextent intheirchoiceofprovider[11].

Anumber ofothercountrieshavealsoinvestedcon- siderableeffortstocollectandpublishdataonoutcomes, provider performanceand patientexperience.Examples inEuropeincludeSweden,theNetherlands,Germanyand England.However,countriesdifferintheextenttowhich theymakesuchdatapubliclyavailable.Englandappearsto havegonefurtherthanmostinprovidingsinglecomposite ratingsofproviderperformance,inadditiontomeasuresof performanceinspecificareas,orusingmulti-dimensional profiles.Forexample,itsCareQualityCommission,thereg- ulatorofhealthandadultsocialcare,generatesacomposite ratingof eachproviderbased onwhethertheyaresafe, effective,caring,responsivetopeople’sneedsandwell-led [12–14].

Thereis, however,littleexplicitly comparativeinfor- mation so far on the current state-of-the-art of public reportinginhigh-incomecountries.Ourstudysoughtto provideacomparativeanalysisofpublicsectorapproaches in 11high-income countriestowards thecollection and publicationofproviderperformancedata.Suchacompar- ativeanalysisisusefulfortworeasons:First,publication ofinformation onproviderperformanceis oftenviewed aspromotingtransparencyontheperformanceofhealth systems.Second,ananalysisofhowapproachesdiffermay revealtheirstrengthsandweaknesses.

ThestudywasundertakenbytheEuropeanObservatory onHealthSystemsandPoliciesinresponsetoarequestof theEnglishDepartmentofHealth.Asummaryoverviewof keyfindingswaspublishedbytheDepartmentofHealth [13].

2. Materialsandmethods

Datawerecollectedbymeansofaquestionnaire(see supplementary web appendix) for self-completion by key informants in Australia, Canada, France, Germany, Netherlands,NewZealand,Norway,Sweden,Switzerland and the United States, exploringthe following areas of publicreporting(i)overallratingsforqualityandsafetyof care(foreverymajorhospital,generalpractice,residential careprovideranddomiciliarycareprovider);(ii)outcomes of individual health care professionals on indicators, suchasmortalityorothermeasuresofperformance;(iii) waiting timesbetweenreferraland treatmentforevery

majorhospital;and(iv)patientexperienceofhospitaland GPservicesforeveryprovider.

The selection of countries was identical to those includedin theCommonwealthFund’ssurvey of health systemsbutwasindependentofit[15].Theselectionof themeswasintendedtorepresentthefullrangeofhealth servicesectors(primarycare,acuteinpatientcare,andres- identialcare)andtoidentifymeasuresthatreflectoverall levelsofperformance.

Key informantswereidentified purposivelyfromthe Observatory’snetworkofexperts,includingitsHealthSys- tems and Policy Monitor (http://www.hspm.org).There were1–3expertsper country, whoworked togetherin completingthequestionnairefortherespectivecountry.

Expertswerechosenonthebasisofhavingdeepinsight intothepolicyprocessinagivencountrythroughactive involvement in research and policydevelopmentand a provenabilitytoreviewnationaldocuments,programmes andinitiativeswithinashortperiodoftime.Datacollec- tiontookplaceinJuly2015andcomprehensiveresponses werereceivedfromeachofthe10countries.ForEngland, thecoordinatingauthors(BR,EN)providedtherequired information. Theyalsoverified information onwebsites providedbytheexperts.

3. Results

3.1. Overallratingsforqualityandsafetyofcare

England istheonlyoneofthe11 countriesincluded inthisanalysisthatpublishesanoverallratingforevery majorhospital(Table1).There,theCareQualityCommis- sionratestheperformanceofhealthcareprovidersonthe basis of 5 dimensions:whethertheyare safe,effective, caring,responsiveandwell-led.Eachprovider(inaddition to acute care hospitals, this includes general practices, carehomesandprovidersofdomiciliarycare–seebelow) is evaluatedonthebasis ofthesedimensionsandcom- posite rankings are then created and published online (http://www.cqc.org.uk/).TheSwedishassociationoflocal authoritiesandregionsSALARpublishedacomparisonof the21countycouncilsusingacompositeof100indicators

in2011[16],butthisisnotbeingdoneonaregularbasis.

Although the comparison is of county councils, most indicatorsrelatetospecialistservices(i.e.hospitals).

Englandisagaintheonlyoneamongthe11countries that publishes an overall rating for general practice.In France,anoverallratingisconstructedbutonlyusedinthe payforperformance(P4P)schemeinambulatorycare.Itis notmadepubliclyavailable.Theremainingninecountries reportedthatnooverall ratinghad beenintroducedfor each individual practice, and none reported plans to doso.

Turning to residential (long-term) care, England, Germany[17]and theUnitedStates[18] weretheonly countriesamongthe11reviewedthatreportedanover- allratingforeveryprovider,whileEnglandandGermany alsoprovideoverallratingsofeveryproviderofdomiciliary carewhicharemadepubliclyavailable[17].Noneofthe othercountriesreportedhavingintroducedsuchratings andnoneseemstohaveplanstointroducethem.

3.2. Ratingofoutcomesofindividualprofessionals

Mortality rates achieved by individual hospital specialists nationwide are only being published in England (https://www.nhs.uk/service-search/

performance/Consultants), although there are excep- tions in parts of the United States, such as New York State,whichpublishesmortalityratesofindividualcardiac surgeons [19], and California, which publishes quality ratings for individual surgeons undertaking coronary arterybypassgraftsurgery[20].

Keyinformants respondingtothesurveynoted con- cerns with regard to conceptual and methodological issues(Norway),ethicalconsiderations(Netherlands),or both (New Zealand and Sweden), with problems iden- tifiedincludingproblemsofattribution, riskadjustment andrandomness, andconcernsover holdingprofession- alsaccountableforoutcomesoutsideoftheircontrol.In NewZealand,concernwasraisedaboutthereliabilityof measuresbasedonsmallnumbers,especiallyinprovincial hospitals,andthelimitationsofsystemsforadjustingfor casemixandcomplexity.

Table1

Overviewofresultsonpublicreportingacrossthedifferentdimensionscovered.

Australia Canada England France Germany Netherlands NewZealand Norway Sweden Switzerland UnitedStates Ratingforoverallqualityandsafety

Eachmajorhospital No No Yes No No No No No No No No

EachGPsurgery No No Yes No No No No No No No No

Eachproviderof residential (long-term)care

No No Yes No Yes No No No No No Yes

Eachproviderof domiciliarycare

No No Yes No Yes No No No No No No

Ratingofoutcomesofindividualprofessionals

Hospitalspecialists No No Yes No No No No No No No No

GPs No No No No No No No No No No No

Waitingtimesforhospitaltreatment

Eachmajorhospital Yes Yes Yes No No Yes No Yes Yes No Yes

PatientexperienceatthelevelofhospitalsorGPpractices

Eachmajorhospital No Yes Yes Yes Yes Yes No Yes Yes Yes Yes

EachGPsurgery No No Yes No No Yes No No Yes No No

Table2

Publicreportingofinformationonwaitingtimesforhospitaltreatmentforeverymajorhospital.

Dataonreferralto treatmenttimes availableforeach majorhospital

Ifsuchdataarenot availableathospital level,atwhichlevel isitavailable?

Websiteifdataarepubliclyavailable Ifdataonreferralto treatmenttimesarenotyet publiclyavailable,arethere planstodevelopthese?

Australia Yes n.a. http://www.myhospitals.gov.au/ n.a.

Canada Yes n.a. www.yourhealthsystem.cihi.ca/hsp/ n.a.

England Yes n.a. https://www.england.nhs.uk/statistics/statistical-

work-areas/rtt-waiting-times/

n.a.

France No None n.a. No

Germany No None n.a. No

Netherlands Yes n.a. http://www.zorgatlas.nl/thema-s/wachtlijsten/

wachtlijsten-ziekenhuiszorg/

n.a.

NewZealand No Regional http://www.health.govt.nz/system/files/documents/

pages/health-target-q3-results-2014-15b.pdf

No

Norway Yes n.a. http://frittsykehusvalg.no/start/# n.a.

Sweden Yes n.a. www.vantetider.se n.a.

Switzerland No None n.a. No

UnitedStates Yes n.a. https://www.medicare.gov/hospitalcompare/ n.a.

None of the 11 countries reported that information onoutcomemeasuresbyindividualGPswasmadepub- licly available and none seemsto have plans todo so.

However,in Germanythere are initiatives at theprac- titionerlevel todevelop sets of indicators (forGPs and specialistsinambulatorycare).IntheUnitedStates,physi- ciansandgrouppracticesassessthequalityofcarethey provide totheir patientsthrough thePhysician Quality ReportingSystem(PQRS)[21].Thisisanoptionalreporting systemforeligibleprovidersofMedicarepatients(30mil- lionelderly),withfinancialpenaltiesfornon-participation.

The PQRS measures for physicians will be publicly available.

3.3. Waitingtimesforhospitaltreatment:referralto treatmenttimes

Informationonwaitingtimesisreportedwidelybythe countriesincludedinthisstudy(Table2).Thisincludesthe publicreportingofdataontimebetweenreferralandtreat- mentforeachmajorhospitalinsixcountries.InGermany and Switzerland, waiting times appear tonot generally beconsidereda ‘problem’ although hospitalscandocu- ment,aspartoftheirreportingofpatientexperience(see alsobelow),whetherpatientshadtowait fortreatment [22]. In New Zealand,the only information reportedas availableisthepercentageofpatientswhoreceivecan- certreatment within 62 days of being referred with a high suspicion of cancer, this being one of 6 national health targets that aimto improve the performance of health services[23]. Thisinformation is, however,pub- lished at districthealth board (DHB) level (responsible for providing or funding the provision of health ser- vicesintheirdistrict)ratherthanindividualhospitallevel (althoughmostDHBshaveonlyonemajorhospitalprovid- ingcancertreatment).IntheNetherlands,informationon waitingtimesisavailableforawiderangeoftreatments, including cardiology, geriatrics, surgery and paediatrics [24], and information on waiting times by specialty is alsoavailableintheothercountriesthatreportwaiting times(Table2).

3.4. Patientexperienceatfacilitylevel

Nineofthe11countriesarereportedtocollectdataon patientexperienceofhospitalcareatthehospitalleveland sevenofthesemakethisinformationavailabletothepublic (Table3).

Regarding general practice, only England, the Netherlands and Sweden appear to make information on patient experience publicly available at the level of individualgeneralpractices.However,Norwayisreported tobeplanningtomakethisinformationpubliclyavailable inthefuture.

4. Discussion

Ourstudycontributestoresearchandpolicybymap- pingcurrentapproachestothepublicreportingofprovider performancedatain11high-incomecountries.Wefound thattheinformationmostcommonlymadeavailabletothe publicisonwaiting timesfor hospitaltreatment.Many countriesalsomakeavailableinformationonpatientexpe- rienceatthehospitallevel,whilesimilardataongeneral practices are currently only available in a minority of countries.

Ourfindingsonthepublicreportingofwaitingtimesare notsurprising.Publicreportingofwaitingtimesforelec- tiveprocedureshasbecomecommoninmanyhigh-income countries,oftencoupledwithpoliciestoincreasepatient choice.Inthosecountrieswherewaitingtimesareapublic concern,theyfigureprominentlyinhealthpolicydebates.

Theyarealsorelativelystraightforwardtomeasurefrom the pointof referral,although theimpact ofpublishing themremainsuncertain[25].

Patient experience of providers at facility level is anothermeasurebeingpublishedinanincreasingnumber ofcountries.Thesedataalsohavetheadvantageofbeing relativelyeasytocapture,although,again,theimpactof publicationontheperformanceandqualityofprovidersis largelyassumedratherthanproven[26].

Englandwastheonlyoneofthe11countriesthatpub- lishescompositeratingsoftheoverallqualityandsafetyof

Table3

Publicreportingofinformationonpatientexperiencesofhospitalcareforeverymajorhospital.

Dataonpatient experienceof hospitalcare availableforeach majorhospital?

Ifsuchdataare notavailableat hospitallevel,at whichlevelare theyavailable?

Websiteifdataarepubliclyavailable Ifdataonpatient experienceofhospitalcare arenotyetpublicly available,arethereplansto developthese?

Australia No Regional Yes n.a.

Canada Yes n.a. www.yourhealthsystem.cihi.ca/hsp/ n.a.

England Yes n.a. http://www.cqc.org.uk/content/inpatient-survey-2014 n.a.

France Yes n.a. No Yes

Germany Yes n.a. https://www.weisse-liste.de/de/krankenhaus/

krankenhaussuche/,

https://weisse-liste.krankenhaus.aok.de/, https://www.krankenhausnavi.barmer-gek.de/

n.a.

Netherlands Yes n.a. www.kiesbeter.nl n.a.

NewZealand No Regional http://www.hqsc.govt.nz/our-programmes/health- quality-evaluation/publicationsand-resources/

publication/2347/

n.a.

Norway Yes n.a. http://www.kunnskapssenteret.no/

publikasjoner#index=0&types=175540

n.a.

Sweden Yes n.a. www.npe.skl.se n.a.

Switzerland Yes n.a. http://www.anq.ch/akutsomatik/akutsomatik-

anq-hplus/

n.a.

UnitedStates Yes n.a. https://www.medicare.gov/hospitalcompare/ n.a.

careprovidedbyhospitalsorGPs.Thismaynotbeacoinci- dence.Althoughcompositeperformanceindicatorsenjoy muchpopularityinthemediaandcanhelptofocusatten- tiononkeyaspectsofperformance[27],theygiveriseto majortechnicalproblemsthathavelongbeenrecognised [28].Arecentstudycomparing‘quality’asmeasuredeither byhospital-widestandardisedmortalityratiosoramuch moredetailedcasenotereview[29],forexample,foundno significantcorrelationbetweenthetwotypesofmeasures, suggestingtheneedforconsiderablecaution.Oneofthe challengesisthattherecanbesubstantialvariationinqual- ityofcareacrossthedifferentdepartmentsofahospital.

Themoredetailedanalysesofqualityofcareare,themore usefultheyseemtobeforqualityimprovementefforts[30], which mighthelptoexplainwhymostcountriesinour studyrefrainedfrompublishingcompositeratings.

Similarly,wefoundthatdataonoutcomesofindividual professionals (such asmortality ratesof individual sur- geonsinparticularspecialities)arepublishedveryrarely, withEnglandandsomepartsoftheUnitedStatesbeing theexceptions.Again,thereluctanceofcountriestopub- lishthistypeofinformationreflectsmethodologicaland ethicalproblems[31].Inparticular,thereisadangerthat healthprofessionalsarebeingblamedforfactorsoutside theircontrol.Furthermore,itcreatesincentivestogame ratings, for example by declining patientswith serious conditions[2].Adeclineinin-hospitalmortalityratesby reducinglengthofstay,forexample,couldbemorethan offsetbyanincreaseinmortalityafterdischarge[3].Pub- lishingdataonoutcomesofindividualprofessionalsmight alsoruncountertotheincreasinglyrecognisedimportance ofworkinginteams.

Amorefundamentalquestionrelatestowhetherpublic reportingofqualityindicatorsingeneralimprovescare.So far,evidenceonthisissueisstillmixed[2].Thereseems tobelittleeffectontheselectionofprovidersbypatients (the selection pathway), while public reporting seems indeed tostimulate quality improvement initiatives by

providers(thechangepathway)[3].Somestudiessuggest thatincentivesthatpursuequalityimprovementsthrough

‘professionalreputationmechanisms’[32]canbestronger than financial incentives [33]. However, there is still onlyscantevidenceofanyimpactofpublicreportingon clinicaloutcomes[3].Arecentsystematicreviewofpublic reportinginhealth careconcludedthatevidenceof any impactofpublicreportingonqualityofcarewaslacking, exceptforapossiblebeneficialeffectfornursinghomes [34].Similarly,astudyofmortalityfromthreeconditions intheUnitedStatesfoundthatMedicare’sPublicReporting Initiativehadmodestornoimpact[35].

Finally,ourstudyalsoraisedtheimportantquestionof whoshouldbeleadingpublicreporting,anissuethatalso emergedinearliersurveys[1,36].Whileourstudyfocused onpublicsectorinitiatives,theyarenottheonlyrelevant actors. However, they have been leading many efforts thathavethenbeentakenupbytheprivatesector.Inthe UnitedStates,manyoftheinnovationsinpublicreporting topatientshave come fromMedicare, thepublicpayer forolderpeople.Theseinnovationsarelikelytospillover intotheprivatesector,if privateinsurersseethevalue ofsuchinformation.Overallqualityandsafetyscoreson hospitalsintheUnitedStatesarepublishedbyLeapfrog Group (http://www.hospitalsafetyscore.org/) and Con- sumerReports(http://www.consumerreports.org/health/

doctors-hospitals/hospital-ratings/state.htm), while the onlinemagazineUSNewsalsopublishesrankingsofhospi- tals (http://health.usnews.com/best-hospitals/rankings).

InEurope,too,thepublicsectorisleadingpublicreporting onquality ofcare, but thereare alsoimportant private sectorinitiatives.IntheNetherlands,forexample,some privatewebsites, newspapersand magazineshavepub- lishedrankingsforcertaintreatmentsandhospitals,such asa listofthetop 100hospitalsproduced bythedaily newspaper, Algemeen Dagblad (http://www.ad.nl/ad/nl/

32488/AD-Ziekenhuistop100/index.dhtml). In Germany, the magazine ‘Focus’ has published a list of the best

hospitals ordered by treatment and diagnosis (http://

focus-abo.de/focus-gesundheit-klinikliste-2013/), although this is based on the views of selected GPs and specialists. In England, rankings of hospitals are publishedbyDr.Foster(http://www.drfoster.com/).

Ourstudywasalsolimitedbyitsfocusonthenational level.However,therearemanypublicreportinginitiatives atthesub-nationallevelthatdeservecloserstudy.Inthe UnitedStates,forexample,therearemanyinitiativesout- sideofMedicarethataretheresponsibilityofthedifferent statesandhealthorganisations,leadingtoenormoushet- erogeneityacrossthecountry.

5. Conclusions

While the provision of appropriate and meaningful informationonhealthcareprovidersisanessentialtool toimprove performanceand increase transparency and accountability[1],notalltypesofinformationareofequal merit [34]. Many countries are working on improving theirqualityreportingsystemswiththeaimofincreas- ingtransparency,butthereappearstobeareluctanceto publishcompositeindicatorsforqualityandsafetyofcare oronoutcomesof individualprofessionals.The reasons forthisare multifacetedand seemtoincludepersistent methodologicalchallenges of risk-adjustment and attri- bution, ethical problems, and concerns about potential unintendedconsequences.

Conflictofintereststatement

The authors declare that they have no conflict of interest.

Acknowledgement

Thisarticleisbasedonareportthatwaspreparedby theEuropeanObservatoryonHealthSystemsandPolicies inarapidresponsetoarequestoftheEnglishDepartment ofHealth.

AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbe found,intheonlineversion,athttp://dx.doi.org/10.1016/

j.healthpol.2016.02.008.

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