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The EFFECT Study: A Randomized Trial

Jack V. Tu, MD, PhD; Linda R. Donovan, BScN, MBA; Douglas S. Lee, MD, PhD; Julie T. Wang, MSc; Peter C. Austin, PhD; David A. Alter, MD, PhD; Dennis T. Ko, MD, MSc

JAMA. 2009;302(21):(doi:10.1001/jama.2009.1731).

Context  Publicly released report cards on hospital performance are increasingly common, but whether they are an effective method for improving quality of care remains uncertain.

Objective  To evaluate whether the public release of data on cardiac quality indicators effectively stimulates hospitals to undertake quality improvement activities that improve health care processes and patient outcomes.

Design, Setting, and Patients  Population-based cluster randomized trial (Enhanced Feedback for Effective Cardiac Treatment [EFFECT]) of 86 hospital corporations in Ontario, Canada, with patients admitted for acute myocardial infarction (AMI) or congestive heart failure (CHF).

Intervention  Participating hospital corporations were randomized to early (January 2004) or delayed (September 2005) feedback of a public report card on their baseline performance (between April 1999 and March 2001) on a set of 12 process-of-care indicators for AMI and 6 for CHF. Follow-up performance data (between April 2004 and March 2005) also were collected.

Main Outcome Measures  The coprimary outcomes were composite AMI and CHF indicators based on 12 AMI and 6 CHF process-of-care indicators. Secondary outcomes were the individual process-of-care indicators, a hospital report card impact survey, and all-cause AMI and CHF mortality.

Results  The publication of the early feedback hospital report card did not result in a significant systemwide improvement in the early feedback group in either the composite AMI process-of-care indicator (absolute change, 1.5%; 95% confidence interval [CI], –2.2% to 5.1%; P = .43) or the composite CHF process-of-care indicator (absolute change, 0.6%; 95% CI, –4.5% to 5.7%; P = .81). During the follow-up period, the mean 30-day AMI mortality rates were 2.5% lower (95% CI, 0.1% to 4.9%; P = .045) in the early feedback group compared with the delayed feedback group. The hospital mortality rates for CHF were not significantly different.

Conclusion  Public release of hospital-specific quality indicators did not significantly improve composite process-of-care indicators for AMI or CHF.

Trial Registration  clinicaltrials.gov Identifier: NCT00187460

Author Affiliations: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (Drs Tu, Lee, Austin, Alter, and Ko and Mss Donovan and Wang); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario (Drs Tu and Ko); Departments of Medicine (Drs Tu, Lee, Alter, and Ko) and Health Policy Management and Evaluation (Drs Tu and Austin), Dalla Lana School of Public Health (Drs Tu and Austin), University of Toronto, Toronto, Ontario; Division of Cardiology, University Health Network, Toronto, Ontario (Dr Lee); Division of Cardiology, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario (Dr Alter); and Toronto Rehabilitation Institute, Toronto, Ontario (Dr Alter).

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