One of the astonishing statistical regularities of human life is the bell curve. Plot the test results of a class of students, the running times of a group of adults, or the blood pressure of men and women, and you will find that they trace out a bell-shaped pattern. At the very edges of the bell are a few people who do very well or very badly. As we move towards the centre there are others who are noticeably below average or above average. And the rest are clustered in the middle. So established is this pattern that statisticians call it “the normal distribution”.
In the case of the medical profession, the same pattern holds. Whenever data on the performance of hospitals or individual doctors is plotted on a curve, large gaps separate the best and the worst. There is nothing surprising in this; most of us can probably imagine the same distribution of performance in our own occupations. Yet it does suggest that choosing the right doctor can be good for your health.
Because information can help more patients choose the best service, and spur reform among the rest, it seems natural to think that data on hospital performance should be made publicly available. (Adjusted, of course, for the fact that some hospitals deal with older and sicker patients than others.)
To her credit, federal health minister Nicola Roxon has been pushing for just this outcome, supported by consumer group Choice. But attempts for more health data to be released into the public domain have been strongly resisted by the Australian Medical Association and some state governments. Their opposition to data release has been based around two arguments - both of which will be familiar to anyone who has followed the debate over the release of schools’ test score data.
First, they argue, the performance measures are imperfect. This is undoubtedly true, but it sets the bar too high. Last week, the Australian Financial Review published its list of Australia’s best lawyers, based on peer assessment. No one would contend that these rankings are flawless, but they nonetheless provide a useful source of information to clients seeking to choose a lawyer, and may spur those who just missed out to lift their game.
Second, those who oppose data being released claim that it will lead to underperforming hospitals being stigmatised. But so long as the data are collected so as to minimise the potential for manipulation, and provide the broadest possible set of indicators, it will help identify the strongest and weakest hospitals. Rather than allowing poor performance to continue under a veil of secrecy, we should let a little sunlight in.
In his book Better: A Surgeon’s Notes on Performance, medical writer Atul Gawande discusses the impact that performance information had on the treatment of cystic fibrosis, a genetic disease that impedes lung capacity. While patients at the average treatment centre typically live to 33 years, those at the best centre typically live to 47. Over recent decades, the life expectancy of cystic fibrosis patients has increased substantially, as treatment innovations have percolated down from the leading centres. On its website, the Cystic Fibrosis Foundation now publishes data on the performance of all its centres in the United States. Yet even in an information-rich environment, the best centres have managed to outperform the rest. Information spurs innovation, but it cannot wipe out the bell curve.
Making hospital performance information publicly available should help all patients, but there are good reasons to think that the poor may benefit more than the rich. Under the current regime, information is restricted to doctors, nurses, and hospital administrators, who naturally share it with their friends. Publishing statistical data on hospital performance would democratise access to information - allowing everyone to see what the insiders already know.
In attempting to change the culture of information in Australian health, it is possible that those in favour of secrecy will prevail. Yet if they do, the effect may be to promote less reliable sources of information. For example, one rapidly growing website allows Australian patients to rate their doctors. But a quick browse shows it to be dominated by the ecstatic and the enraged. (Moreover, you also have to wonder about a site in which the infamous Queensland surgeon Jayant Patel is rated “average”.) The more comprehensive public data is, the less individuals will need to rely upon questionable sources of information.
Just as in the case of schools, making data on hospitals publicly available is a useful first step to spur reform. When insiders claim that the public can’t handle the truth, we should respond that taxpayers have a right to receive feedback on the services we fund. The more we can learn from the best, the better our public services can become.
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