Public report cards for PICU performance?

The short answer is that there aren’t any. I’ve written before about how hard it is for parents to know if the PICU there child is in is a good one or not. All they can really do is see if the components of a good PICU are in place: is the facility state-of-the-art, is it staffed by board-certified pediatric intensivists and pediatric surgical specialists, and do the intensivists have the assistance of the full array of subspecialists if your child needs them. But what parents really want to know is how the results of the PICU, the patient outcomes, stack up against similar units. Even we intensivists have little such information, and what we have isn’t available to parents. The biggest problem standing in the way of even collecting such information is the hugely varied mix of children who need the PICU, so in comparing PICUs we would need to be sure that we aren’t comparing apples to oranges.

One aspect of PICU practice that is fairly standard from place to place is heart surgery; the surgery is similar from child to child, and all children who have heart surgery need the PICU afterwards. The skill of the surgeon, of course, is the biggest variable in how the children do, but the competence of the PICU team is also a key factor.

I’m not aware of any data that compares outcomes among PICUs following heart surgery (or any other condition), but now we do have such information for adult heart surgery. Here is a very good recent editorial from The New England Journal of Medicine discussing what the implications are of such information. One important potential negative effect would be cherry-picking — doctors or hospitals avoiding caring for very sick patients out of fear of worsening their report card. From the article:

“There is no question about the need for accountability on the part of health care providers or the central role of measurement in the improvement of health care. Nonetheless, questions remain about the role of public reporting in improving health care. Performance measurements audited by regulators are one alternative, especially in situations in which the information is too complex for patients to use in discriminating among care sites. Insofar as public reporting drives improvement of all outcomes, it benefits everyone; insofar as risk aversion leads to changes in the population receiving an indicated service, the net effect can be nil or even negative.”

I think that this sort of reporting is something all of us in critical care, PICUs included, will ultimately be seeing.


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