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10. Glance LG, Osler TM, Dick AW, Mukamel DB, Meredith W. The Survival Measurement and Reporting Trial for Trauma (SMARTT): background and study design. J Trauma. 2010;68(6):1491-1497.

19. National Trauma Data Bank. National Trauma Data Standard data dictionary version 1.2. 2008; http://www.ntdsdictionary.org/. Accessed November 20, 2013.

11. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4): 366-378.

20. Shadish WRCT, Campbell DT. Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Independence, KY: Wadsworth Publishing; 2002.

12. Shafi S, Friese R, Gentilello LM. Moving beyond personnel and process: a case for incorporating outcome measures in the trauma center designation process. Arch Surg. 2008;143(2):115-119, discussion 120.

21. Yörük BK, Yörük CE. The impact of minimum legal drinking age laws on alcohol consumption, smoking, and marijuana use: evidence from a regression discontinuity design using exact date of birth. J Health Econ. 2011;30(4):740-752.

13. Glance LG, Dick AW, Mukamel DB, Meredith W, Osler TM. The effect of preexisting conditions on hospital quality measurement for injured patients. Ann Surg. 2010;251(4):728-734.

22. van Buuren S, Boshuizen HC, Knook DL. Multiple imputation of missing blood pressure covariates in survival analysis. Stat Med. 1999;18(6):681-694.

14. American College of Surgeons. National Trauma Data Bank Report 2012. http://www.facs.org /trauma/ntdb/docpub.html.

23. Royston P, Altman DG. Regression using fractional polynomials of continuous covariates: parsimonious parametric modeling. Appl Stat. 1994;43:429-467. doi:10.2307/2986270.

15. American College of Surgeons. National Trauma Data Bank Reference Manual. Chicago, IL: American College of Surgeons; 2002. 16. American College of Surgeons. National Trauma Data Bank User Manual Research Data Set version 7.0. Chicago, IL: American College of Surgeons; 2008. 17. Osler T, Glance L, Buzas JS, Mukamel D, Wagner J, Dick A. A trauma mortality prediction model based on the anatomic injury scale. Ann Surg. 2008;247(6):1041-1048. 18. Glance LG, Osler TM, Mukamel DB, Meredith W, Wagner J, Dick AW. TMPM-ICD9: a trauma mortality prediction model based on ICD-9-CM codes. Ann Surg. 2009;249(6):1032-1039.

the Evidence for Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2013:140-156. 28. Glickman SW, Ou FS, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA. 2007;297(21):2373-2380. 29. Ryan AM. Effects of the Premier Hospital Quality Incentive Demonstration on Medicare patient mortality and cost. Health Serv Res. 2009;44(3):821-842. 30. Khuri SF, Daley J, Henderson WG. The comparative assessment and improvement of quality of surgical care in the Department of Veterans Affairs. Arch Surg. 2002;137(1):20-27. 31. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA. 2010;303(24):2479-2485.

24. DeLong ER, Peterson ED, DeLong DM, Muhlbaier LH, Hackett S, Mark DB. Comparing risk-adjustment methods for provider profiling. Stat Med. 1997;16(23):2645-2664. 25. White H. A heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity. Econometrica. 1980;48:817-830. doi:10.2307/1912934. 26. Khuri SF. The NSQIP: a new frontier in surgery. Surgery. 2005;138(5):837-843. 27. Maggard-Gibbons M. Use of Report Cards and Outcome Measurements to Improve Safety of Surgical Care: American College of Surgeons National Quality Improvement Program. Making Health Care Safer II: An Updated Critical Analysis of

32. Werner RM, Bradlow ET. Public reporting on hospital process improvements is linked to better patient outcomes. Health Aff (Millwood). 2010;29(7):1319-1324. 33. Shafi S, Nathens AB, Cryer HG, et al. The Trauma Quality Improvement Program of the American College of Surgeons Committee on Trauma. J Am Coll Surg. 2009;209(4):521-530.e531. 34. American College of Surgeons. Trauma Quality Improvement Program (TQIP). http://www.facs.org /trauma/ntdb/tqip.html. Accessed March 8, 2013. 35. Blumenthal D, Dixon J. Health-care reforms in the USA and England: areas for useful learning. Lancet. 2012;380(9850):1352-1357.

Invited Commentary

Hospital Report Cards Necessary but Not Sufficient? Justin B. Dimick, MD, MPH; Samantha K. Hendren, MD, MPH

Performance feedback is increasingly used as a strategy to motivate surgeons to improve. Numerous surgical specialties have launched clinical registries to generate reports of risk-adjusted outcomes including cardiac, bariatric, g e n e r a l , v a s c u l a r, a n d trauma surgical procedures. Related article page 137 These reports are fed back to hospitals, allowing them to identify problem areas such as higher-than-expected complication rates. In theory, hospitals then implement changes to address these shortcomings. Proponents of performance feedback argue that hospitals and surgeons, once they know where they do not measure up, will make the necessary changes to improve outcomes. However, many believe that this view is too optimistic; that is, that feedback alone is not enough to spur improvement. In this issue of JAMA Surgery, Glance et al1 provide strong evidence supporting the latter.

Glance et al 1 conducted a rigorous evaluation of the impact of performance reports on risk-adjusted mortality for trauma patients. The study was a natural experiment in the setting of the National Trauma Data Bank (NTDB) maintained by the American College of Surgeons. Using an interrupted time-series design, Glance et al1 found no improvement in mortality (no change in the slope) after NTDB began providing benchmarking reports to hospitals. The methods in the study are state of the art and leave very little room for criticism. Therefore, we believe the study provides strong evidence that, in this context, performance reports are not enough to motivate improvement. Although this study is among the first to rigorously evaluate performance feedback in surgery, there is a robust literature in other health care settings. A recent Cochrane metaanalysis demonstrated a positive, but very small, benefit of the effectiveness of audit and feedback alone on physician performance.2 Because the reports in the NTDB are provided

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to hospitals and not individual physicians, it is not surprising that they had less of an impact. Physicians have influence over their own behavior, but trauma center directors may find it more of a challenge to change the behavior of a large group of individuals such as the physician and nonphysician staff at a trauma center. How can we better use performance reports to change practice? We first need to be clear that measurement and improvement are different activities. Generating hospital report cards—quality measurement—is an exercise in data collection and statistical analysis. Optimizing the delivery of care— performance improvement—is an exercise in leadership and implementing change. Most resources in physician-led registries focus on increasing the sophistication of measurement. Although this is no doubt important, resources should also be invested to understand how reports are used and create an infrastructure to support implementing change. A first step at understanding why the efforts of the NTDB fell short of improving quality would be to qualitatively examine exactly how the reports were used or not used. This could be done by interviewing surgeon champions to examine the extent to which they used the reports to initiate improvement activities.3 Performance reports will not motivate change if they are collecting dust on someone’s desk. Regardless of the underlying use, or lack of use, of performance reports, it is clear that specialty societies need to do more to guide hospitals in improvement work. The status quo ranges from doing nothing to dissemination of pamphlets describing best practices, case studies, and other low-level educational activities. A robust body of evidence suggests that disseminating these materials without an implementation strategy

ARTICLE INFORMATION Author Affiliations: Department of Surgery, University of Michigan, Ann Arbor. Corresponding Author: Justin B. Dimick, MD, MPH, Department of Surgery, University of Michigan, 2800 Plymouth Rd, Bldg 16, Ste 137E, Ann Arbor, MI 48109 ([email protected]). Published Online: December 11, 2013. doi:10.1001/jamasurg.2013.3996. Conflict of Interest Disclosures: None reported.

is marginally better than feedback alone.2 Surgical professional associations, which lead many of these programs, should provide more rigorous improvement programs that draw on the rich methods of implementation science to ensure that change efforts have an impact. Perhaps the most successful model for implementing change is that of regional quality-improvement collaboratives. These programs focus on building relationships between participating centers and provide a robust platform for implementing change. This model has been highly successful at improving outcomes in cardiac, bariatric, general, and vascular surgical procedures.4 For national programs that do not have the luxury of meeting face to face several times a year, a different approach is needed. One example, pioneered by the Society of Hospital Medicine, is known as mentored implementation. Frustrated by the lack of adoption of its clinical guidelines, the Society of Hospital Medicine developed infrastructure and provided a formal mentoring process, where sites that have been successful at certain initiatives provide active coaching to hospitals implementing new guidelines.5 The study by Glance et al1 should be an important wake-up call: outcomes feedback is necessary, but not sufficient, to improve quality. Despite the growth in the use of performance feedback, there is a large gap between what we are currently doing and what needs to be done to improve outcomes for our patients. Developing an implementation strategy to close this improvement gap should be a top priority for any program that aims to improve outcomes. We need to stop hoping that surgeons and hospitals will improve on their own and start to disseminate both the data and the scientific tools to promote performance improvement.

2. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6:CD000259. 3. Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci. 2013;8:70. 4. Share DA, Campbell DA, Birkmeyer N, et al. How a regional collaborative of hospitals and physicians

in Michigan cut costs and improved the quality of care. Health Aff (Millwood). 2011;30(4):636-645. 5. Maynard GA, Budnitz TL, Nickel WK, et al. 2011 John M. Eisenberg Patient Safety and Quality Awards: mentored implementation: building leaders and achieving results through a collaborative improvement model: innovation in patient safety and quality at the national level. Jt Comm J Qual Patient Saf. 2012;38(7):301-310.

REFERENCES 1. Glance LG, Osler TM, Mukamel DB, Meredith JW, Dick AW. Effectiveness of nonpublic report cards for reducing trauma mortality [published online December 11, 2013]. JAMA Surgery. doi:10.1001/jamasurg.2013.3977.

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