Skip to main content

The impact of Public Reporting on clinical outcomes: a systematic review and meta-analysis



To assess both qualitatively and quantitatively the impact of Public Reporting (PR) on clinical outcomes, we carried out a systematic review of published studies on this topic.


Pubmed, Web of Science and SCOPUS databases were searched to identify studies published from 1991 to 2014 that investigated the relationship between PR and clinical outcomes. Studies were considered eligible if they investigated the relationship between PR and clinical outcomes and comprehensively described the PR mechanism and the study design adopted. Among the clinical outcomes identified, meta-analysis was performed for overall mortality rate which quantitative data were exhaustively reported in a sufficient number of studies. Two reviewers conducted all data extraction independently and disagreements were resolved through discussion. The same reviewers evaluated also the quality of the studies using a GRADE approach.


Twenty-seven studies were included. Mainly, the effect of PR on clinical outcomes was positive. Meta-analysis regarding overall mortality included, in a context of high heterogeneity, 10 studies with a total of 1,840,401 experimental events and 3,670,446 control events and resulted in a RR of 0.85 (95 % CI, 0.79-0.92).


The introduction of PR programs at different levels of the healthcare sector is a challenging but rewarding public health strategy. Existing research covering different clinical outcomes supports the idea that PR could, in fact, stimulate providers to improve healthcare quality.

Peer Review reports


Public reporting (PR) is a mechanism of “providing data about a health care structure, process, or outcome publicly available or available to a broad audience free of charge or at a nominal cost, in order to be able to compare data across providers or to a national/regional data report on performance for which there are accepted standards or best practices” [1]. Public release of quality and clinical performance of the healthcare providers is becoming increasingly common among the healthcare systems worldwide. Policy and decision-makers in a demand-driven healthcare system are becoming more interested in having information about quality performance [2] and thereby PR has been proposed as a mechanism for providing more transparency and accountability of healthcare providers [3]. Constant improvement of the quality of care should be one of the top priorities of healthcare providers [4]. According to the theory of PR, healthcare users are expected to inform themselves about the quality of healthcare system before selecting the particular provider and so those with high performance would be rewarded by selecting, while low performers would be avoided and thereby stimulated to improve their performance [58].

There have been suggested several pathways through which quality might be improved after the release of performance data. First pathway, the selection pathway, proposed by Berwick et al., is based on the concern of healthcare providers about their market share, where consumers choosing better performers, motivate providers’ efforts to improve quality in order to attract more patients. The change pathway, also proposed by Berwick et al., is based on the concept that identifying quality deficits is sufficient to stimulate the professional motivation of clinicians and organizations to improve [9]. After observing in their study that these two pathways were a relatively weak stimulus to action, Hibbard et al., introduced the third pathway - the reputation pathway, based on the premise that providers which perform poorly, after being identified through the PR, suffer damage to their reputation and further motivate quality improvements in order to protect or improve reputation [10].

PR of clinical outcomes data is a great tool for increasing the transparency in healthcare which enables patients to make informed choices about their healthcare. The most convincing rationale for the PR of clinical outcomes is the one’s right to be aware of the quality of care that he/she is likely to receive from providers [11]. Cardiac surgery has been a pioneer field for the publication of clinical outcomes, since being among the most frequently performed complex surgical procedures [12]. The collection and publication of standardized military hospital mortality rates by Florence Nightingale in 1863 where highlighting the differences in mortality rates between hospitals is believed to be the earliest attempt of PR of clinical outcome and in general [13]. The modern practice of PR systems started in the late 1980s in the USA with the introduction of Coronary Artery Bypass Graft (CABG) report cards of New York State Department of Health, as the first state wide program where the risk adjusted post-operative mortality rates following CABG surgery are being published at the level of both the hospital and the individual surgeon resulting in a 41% decline in risk-adjusted CABG mortality rate [14]. In Europe, back in 1994, Scotland was the first to adopt PR with the Clinical Resource and Audit Group (CRAG) [15]. After these initiatives, other countries have started to follow their example and implement PR into their healthcare systems.

Several authors, over the years have studied the effects of PR on clinical outcomes and, still nowadays, there are inconsistent results in the literature. The review of healthcare PR by Fung et al. found mixed signals among the studies of the effect of PR on outcomes, with some studies showing no effects and others showing minimal effects. Indeed the authors concluded that a solid evidence is still lacking and the systematic evaluation of many major PR systems is needed [5]. The scarcity of a solid evidence does not necessarily suggests the lack of effect and, since the publication of Fung et al., many studies have been conducted to explore the effect of public release of performance data on clinical outcome, but always with incoherent results. Thus, we took the aim to perform an up-to-date systematic review of scientific literature in order to synthesize, both qualitatively and quantitatively, the impact of PR on clinical outcomes.


A protocol was developed and a systematic review and a meta-analysis were conducted and reported in accord with PRISMA guidelines for meta-analyses and systematic reviews [16].

Search strategy and study selection

A literature search was performed by accessing Pubmed, Thomson Reuters Web of Science and Scopus databases to identify studies that investigated the relationship between PR and clinical outcomes. The search terms “public reporting”, “quality reporting”, “information dissemination”, “data shar*” and “report card*” were used, by specifying “health” for databases that also covered non-health topics.

Our search was restricted to English language studies published from 1st January 1991 to 31st December 2014. Studies were considered eligible if they comprehensively described the PR mechanism in terms of subjects, setting, location and dissemination way, if the study design adopted was clearly described and if they investigated the relationship between PR and clinical outcomes. Studies not reporting original data as well as studies focusing only on non-clinical effects of PR were excluded.

Two reviewers independently screened titles and identified abstracts of relevant titles. Full texts of potential citations were subsequently obtained and independently screened by the two reviewers for inclusion. Disagreements were resolved through discussion. Additional relevant publications were identified from the references of the initially retrieved articles.

Data extraction and analysis

From each study data on the first author’s last name, year of publication, objective, subject, setting, location, PR mechanism, clinical outcome assessed and key findings were extracted. For each clinical outcome assessed, quantitative data were also extracted if available.

Two reviewers conducted all data extraction independently and disagreements were resolved through discussion. The same reviewers evaluated also the quality of the studies using a GRADE derived approach (see Additional file 1) [17].

Among the clinical outcomes evaluated, meta-analysis was performed for overall mortality rate which quantitative data were exhaustively reported in 10 different studies. Because of the significant heterogeneity expected among the studies performed in different settings, the random effects model was employed using the Der Simonian and Laird’s method [18].

Heterogeneity was quantified using the Cochran Q test and I2 statistics [19] and subgroup analyses were performed for different study design and setting.

Sensitivity analyses were conducted by excluding one study at a time from the meta-analysis to determine whether the results of the meta-analysis were influenced by individual studies and whether risk estimates and heterogeneity were substantially modified.

The presence of publication bias was assessed using the Egger’s test [20].

All analyses were carried out using Review Manager, version 5.2.7 for Mac (The Nordic Cochrane Centre, Copenhagen, Denmark) and Stata, version 13.1 for Mac (StataCorp, College Station TX, USA).


Characteristics of the studies

We identified a total number of 22,404 studies through Pubmed, Thomson Reuters Web of Science, Scopus online databases search. After removing the duplicates, 10,578 studies were left, and, carefully reading the titles, 2,145 studies were assessed for eligibility. Further step was reviewing the abstracts, and 254 full text articles were obtained. By not fulfilling the inclusion criteria, 231 full text articles were excluded, and 4 were individuated from the screening of references list of studies that fulfilled inclusion criteria, leaving 27 studies to be included in our analysis [14, 2146]. Figure 1 depicts the process of literature search and study selection.

Fig. 1
figure 1

Flowchart depicting literature search and study selection

The publication years of the studies were ranged from 1994 [21] until the most recent ones, from 2014 [4446]. Most of the 27 studies included in our review (N = 23) were carried out in the US [14, 2130, 3239, 4144], one in Canada [31] and Italy [40], and the remaining two in China [45, 46]. Twelve were cohort studies in which the control and study cohorts of patients were taken from different facilities over the same period of time [23, 26, 29, 33, 35, 38, 39, 4246], 14 were cohort studies in which the control and study cohorts of patients were taken from the same facilities before and after the introduction of a PR mechanism [14, 21, 22, 24, 25, 27, 28, 3032, 34, 36, 37, 41], while the remaining study used both cohort designs [40]. The majority of the studies included in this review presented performance information in the form of “report cards”, while the others used different forms to communicate data to the public (Table 1).

Table 1 Characteristics of the included studies and effects of PR on clinical outcomes

There were several clinical outcomes examined throughout the studies. Many investigated the effect of PR on patients’ mortality [14, 2133, 3539, 41, 43, 44]. Other aims in these studies included investigation of cardiac readmission to hospital [28, 37], antibiotic use, and waiting times to see a physician [34], injection prescribing rates [45], Percutaneous Coronary Intervention (PCI) rates, hip fractures operated on within 48 h, cesarean deliveries [40], change in CABG operations volume [14], improvements in infection prevention [42] and patient choices [36].

We included a total number of 27 studies in our systematic review that evaluated the effect of PR on clinical outcomes and the results are summarized in Table 1. Mainly, the effect of PR on clinical outcomes was positive. Fourteen studies reported positive results [14, 2123, 25, 3033, 36, 37, 40, 44, 45], nine reported not significant results [26, 27, 29, 34, 35, 38, 4143], three studies reported mixed results [24, 39, 46], some positive and some negative or null, while one study reported a negative effect [28].

We used a GRADE derived approach to assess the quality of the included studies. The body of evidence in our review was characterized by a low quality level (see Additional file 1). Indeed, the study design was, in almost all of the studies, observational, and there were a number of limitations. When a pre-post approach at hospital level was used to assess the performance before and after the release of PR, there was no external control group for comparison. Moreover, there was no information on institutions and participants that were lost-to-follow-up during the study period. Also, the different outcomes, for institutions with and without PR, could be influenced by some characteristics not measured across the studies.

Effects of public reporting on mortality

The effect of PR on mortality, as isolated clinical outcome, was evaluated throughout 22 studies [14, 2133, 3539, 41, 43, 44]. All studies were set in hospitals, in the US and Canada, and 19 of them were on cardiac patients and used PR data mostly from specific CSRS. A positive effect of PR on mortality was reported in 12 studies [14, 2123, 25, 3033, 36, 37, 44].

Two studies reported mixed effect of the PR on patients’ mortality. Baker et al. [24] demonstrated that, for most conditions, after the release of PR, risk-adjusted in-hospital mortality declined and mortality rate in the early post discharge period rose, while the 30-day mortality rate declined for heart failure and obstructive pulmonary disease and increased for stroke, while Joynt et al. [39] stated no differences in reporting versus non reporting states for overall mortality among patients with acute myocardial infarction (AMI), except among Medicare beneficiaries with AMI [39].

The only study in our review that reported a negative effect of PR was a cohort study from Dranove et al. [28], where the authors showed a statistically marginal evidence that after releasing the report cards, the average mortality rate in New York and Pennsylvania hospitals performing CABG increased by 0.45 percentage point on a base of 33 %. The remaining 7 studies reported non-significant effect of PR on mortality [26, 27, 29, 35, 38, 41, 43].

Ten out of the 22 studies investigating mortality as an outcome [22, 23, 26, 2831, 38, 39, 41] reported sufficient quantitative data to be pooled through meta-analysis. Overall, this analysis included a total of 1,840,401 experimental events and 3,670,446 control events. The meta-analysis resulted in a RR of 0.85 (95 % CI, 0.79-0.92) in a contest of high heterogeneity (p ≤ 0.0001; I2 = 99.1 %) (Fig. 2). Publication bias was not evident using the Egger’s test (p = 0.91). We also performed a one-way sensitivity analysis, where one by one study was omitted from the overall meta-analysis, but no significant change in risk estimates was noticed.

Fig. 2
figure 2

Meta-analysis of the PR effect on mortality as clinical outcome by facilities

A subgroup analysis on mortality by study design was also carried out. The six publications [22, 23, 28, 30, 31, 41] reporting mortality rates in the same facilities during different periods showed a RR of 0.85 (95 % CI, 0.76-0.94) in a context of high heterogeneity (p < 0.0001; I2 = 100 %). Whilst, the four included studies [26, 29, 38, 39] recording mortality rates during the same period in different facilities showed a RR of 0.91 (95 % CI, 0.85-0.97) in a context of high heterogeneity I2 = 95 % (p < 0.0001) (Fig. 2). Test for subgroup differences resulted negative with a p value of 0.28.

Another subgroup analysis was performed by studies considering different mortality causes. Pooling the results from studies focused on mortality from cardiovascular disease, six studies were included [23, 2831, 39] and a RR of 0.83 (95 % CI, 0.77-0.91) was calculated, with high heterogeneity (p < 0.0001; I2 = 95 %). For the subgroup of studies that included patients with a wide range of conditions [22, 26, 38, 41], a RR of 0.91 (95 % CI, 0.83-0.99) was obtained, with heterogeneity I2 = 99 % (p < 0.0001) (Fig. 3). Test for subgroup differences resulted negative with a p value of 0.18.

Fig. 3
figure 3

Meta-analysis of the PR effect on different mortality causes as clinical outcomes

Effects of public reporting on other clinical outcomes

Other clinical outcomes, beside mortality, were explored in 8 studies [28, 34, 37, 39, 40, 42, 45, 46]. In an Italian study performed by Renzi et al. [40], a pre-post evaluation of clinical outcomes in Lazio Region was done and also a comparative evaluation versus Italian Regions without comparable PR programs. The study demonstrated that in Lazio the PCI within 48 h from admission increased from 22.49 to 29.43 % following the reporting of the Regional Outcome Evaluation Program (P.Re. Val.E) results. In the other regions without comparable programs, during the same period, this proportion increased from 22.48 to 27.09 %. Hip fractures operated on within 48 h from admission increased in Lazio, while not in other regions with no PR. Cesarean deliveries did not decrease in Lazio (from 34.57 to 35.30 %), while only slightly decreased in the other regions (from 30.49 to 28.11 %) [40]. Joynt et al. [39] reported that after implementation of PR, odds of undergoing PCI in Massachusetts where PR was present decreased comparing with non-reporting states (41.1 % vs 45.6 %; OR = 0.81; 95 % CI = 0.47- 1.38; P = 0.03). Marsteller et al. [44] in one cohort study on patients from 1,046 adult intensive care units found reductions in central line-associated bloodstream infections (CLABSIs) rates in the first 6 months from the release of PR, compared to the units from the states with no reporting mechanisms. During months 13–18, groups with mandatory PR of data about CLABSI showed a trend toward greater reduction in CLABSI compared with states with no PR [44]. Hospital readmissions were evaluated in two studies. Dranove et al. [28] reported a negative effect of PR, with a significantly increased average rate of readmissions with heart failure by approximately 0.5 percentage point. On the other hand, more recently, Werner et al. [37] reported performance improvements for AMI in terms of declines in readmission rates beside lengths-of-stay and mortality rates.

Studies set up outside hospital settings [45, 46] addressed different clinical outcomes, such as antibiotic prescription and usage as well as injection prescribing rates, in primary healthcare institutions. Yang et al. [46] evaluated the impact of PR on antibiotic prescribing for upper respiratory tract infections (URTIs) demonstrating that PR interventions reduced the incidence of oral antibiotic prescription and slowed down the increase of combined use of antibiotics for URTIs in primary healthcare setting. According to Wang et al. [45], PR led to a reduction of approximately 4 % in the injection prescribing rate four months after intervention (OR = 0.96; 95 % CI: 0.94, 0.97), although with an inconsistent effect in each month after intervention.


The public release of hospital performance data has been recommended as one key strategy for stimulating improvement of quality of care by putting the focus on transparency and accountability of healthcare providers. Also, PR is expected to stimulate active patients/citizens participation by helping them make informed choices when choosing health care providers [47].

According to Berwick, PR can improve performance through 2 pathways. In the Improvement through Selection pathway, patients and providers could shift care from low-quality to high-quality hospitals by using the publicly disclosed reports of hospital performance quality and thereby stimulating quality improvement efforts for the benefits of market share. In the Improvement Through Changes in Care (or quality improvement) pathway, published performance data can identify areas in which providers had low accomplishment and help them to focus on improving performance, by appealing to their professionalism or their concern about reputation or direct market position. As well, it is more likely that quality improvement happens in combination of these two pathways [9].

Nowadays, PR is a more and more common health policy tool to stimulate and maintain quality improvement of health care. There is a growing international interest in providing the necessary information of clinical quality and performance of healthcare providers [48]. Many studies of PR performance data have been published so far, but available reviews of the association between clinical outcomes and public disclosure of performance data are limited.

In our systematic review on impact of PR on clinical outcomes, we identified 27 new articles published since 1994. These studies, which were mostly hospital-level and had medium global ratings, focused primarily on mortality rates and cardiac procedures. Ten studies found that mortality rates decreased after PR, while nine studies did not find a significant link between PR and improvement.

Most of the studies examined the impact of USA and Canada PR of mortality rates for cardiac surgery (CABG and PCI). Different reporting systems were evaluated across the publications. Many studies that we found, were focusing their research on the same group of reporting systems like NYS CSRS which is considered as a pioneer among PR systems, despite the fact that nowadays many PR systems are available on the market [14]. Also studies comparing effectiveness among different PR systems are lacking. Many studies used reporting systems based on cardiovascular outcomes, including surgical interventions, hospitalization and mortality. In our review, we found seven studies based on the NYS CSRS [14, 21, 23, 25, 28, 32, 39], four studies on Cleveland Health Quality Choice Program (CHQC) [22, 24, 26, 27], as well as Medicare’s PR initiative [35, 37, 41, 42]. Other studies used various state-level PR data sources. The majority of the studies (N = 25) were placed in hospital settings [14, 2123, 26, 27, 2938, 4043], and two in primary healthcare institutions [45, 46].

As opposed to the studies performed in the hospital setting, little information is available from the literature regarding the effectiveness of PR in primary care settings. Translating knowledge and experience from one healthcare setting to others is a reasonable method for building the high-quality healthcare service everywhere [49]. Two studies included in this review [45, 46] demonstrated that PR can have an impact on medication prescription and usage in primary healthcare settings. The authors concluded that even though further clinical outcomes of such an impact were not investigated in their studies, a positive effect might be expected. To the best of our knowledge, our review is the first to tackle the effects of PR in primary care setting, so additional research is still needed to further investigate the mechanism by which public reporting takes effect in outside-hospital settings.

Our research, including 27 studies carried out in North America, Europe and China, was mainly conclusive with the previously published reviews of public reports, whereas the effect of the PR on clinical outcomes was in our qualitative and also, through meta-analysis technique, quantitative assessment positive for patients in the hospital setting and primary healthcare but with a low quality of the evaluated studies. In one of the first reviews about PR, Marshall et al. [50] showed improvement in health outcomes among 7 PR systems based in the USA. In 2008, a systematic review of 11 studies by Fung et al. [5], showed inconsistent association between PR and effectiveness on patient outcomes. They reported that studies of the effect of PR on outcomes provided mixed signals and that most of the evaluated studies were descriptive and had low global ratings thus limited strength of evidence. They also concluded that PR stimulated quality improvement activity in hospitals and yet did not affect hospital selection by patients and generally was limited to a few clinical areas, like cardiac surgery. In one recent report, Specchia et al. [51] performed a review on the use of publicly released performance data and concluded that the introduction of standard set of evidence based outcomes and performance measures at national level could reduce the pressure from the selection of performance measures to be disseminated through the PR and make health care providers aware of the importance of transparency and accountability. They also concluded that it would be very effective to link PR to Pay-for-Performance (P4P) systems by basing payments on outcome results and thereby supporting the quality improvement process.

Strengths and limitations

This review has some strengths and limitations. The comprehensiveness, the focus on clinical outcomes and the attempt to provide a quantitative synthesis of the available evidence are strengths of this review. Our search, in fact, covered a wide time interval and a variety of settings including both hospitals and primary care institutions and results has been synthetized both qualitative and, for mortality outcome, quantitative through meta-analysis technique. However, because of the resulting heterogeneity, caution should be placed in interpreting the results of the quantitative synthesis made for mortality outcome.

Some studies [14, 21, 43] have also noted how, after the introduction of PR, structures starting from a lower quality level have a greater propensity to improve their quality compared to those starting from an already high level of quality. Difference in starting levels of quality between the different hospitals and institutions when introducing PR is also a source of heterogeneity among the studies included in our review.

Limitations are also present due to the observational nature of the included studies. Indeed, the studies which control and study cohorts were taken from the same facilities before and after the introduction of a PR mechanism may have overestimated the effect of PR, because of a technological improvement trend running parallel to the adoption of the PR [41].

Search strategy was also limited to English language studies published from 1991 and most of published evidence concern cardiovascular disease in hospital setting.

Policy implications

PR can be considered as one of the key drivers for transparency and accountability in the public health field. Far from providing a quantitative estimate of the current use of PR, the experiences described in this paper can represent a framework of opportunities for changing the relationship between patients/customers and healthcare providers and as a tool to support policy makers in addressing and allocating resources according to the assessment of providers’ performances and the publication of their results which are accessible and understandable to all of the stakeholders, including patients/customers.

Several successful examples of stakeholder involvement in the processes deriving from PR have been described both in the United States [50] and in Europe, as in Netherlands [52] or Germany [53]. In particular WHO Regional Office for Europe suggested key considerations for a successful strategy to encourage providers in improving the quality of services, the accountability of processes, the identification of failures, and providing with the use of publicly reported quality information strengthening communication tools, supporting public health professionals and making clearer consequent decisions [54].

The decision-making is always a difficult process for patients. To obtain informed choices high levels of numeracy and literacy are needed and PR can be considered a useful instrument to face this issue. Therefore, policy makers should support good practices in Public Health especially those, such as PR, focused on increased patient awareness.

Moreover, health policies should be promoted with the aim to integrate different strategies pursuing quality and excellence in healthcare. For example, linking PR to P4P, and therefore to remuneration for incentives schemes based on performance data, would strengthen the competitiveness of the whole system, triggering at the same time a virtuous circle oriented to the increase of both appropriateness and continuous quality improvement of healthcare [51].


The introduction of PR programs at different levels of the healthcare sector is a challenging but rewarding public health strategy. Existing research covering different clinical outcomes supports the idea that PR could, in fact, stimulate providers to improve healthcare quality.

Transparency and accountability resulting from PR implementation not only give patients those information tools customers commonly are able to access in many other sectors, but are key points in the process that make patients and citizens empowered protagonist of their care.


AHRQ, Agency for Healthcare Research and Quality; AMI, acute myocardial infarction; CABG, Coronary Artery Bypass Graft (CABG); CAHPS, Consumer Assessment of Healthcare Providers and Systems; CHQC, Cleveland Health Quality Choice Program; CLABSIs, central line-associated bloodstream infections; CRAG, Clinical Resource and Audit Group; HQID, Hospital Quality Incentive Demonstration program; NYS CSRS, New York State Cardiac Surgery Reporting System; P4P, pay-for-performance; PCI, Percutaneous Coronary Intervention; PR, Public Reporting; URTIs, upper respiratory tract infections (URTIs)


  1. Totten AM, Wagner J, Tiwari A, O’Haire C, Griffin J, Walker M. Closing the quality gap: revisiting the state of the science (vol. 5: public reporting as a quality improvement strategy). Evid Rep Technol Assess (Full Rep). 2012;5:1–645.

  2. Smith P, Mossialos E, Papanicolas I. Performance measurement for health system improvement: experiences, challenges and prospects. WHO Eur Minist Conf Heal Syst. 2008;1:1–22.

  3. Lansky D. Improving quality through public disclosure of performance information. Health Aff. 2002;21:52–62.

    Article  Google Scholar 

  4. Hibbard JH. What Can We Say about the impact of public reporting ? inconsistent. Ann Intern Med. 2012;148:160–1.

    Article  Google Scholar 

  5. Fung CH, Lim Y, Mattke S, Damberg C, Shekelle PG. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med. 2008;148:111–23.

    Article  PubMed  Google Scholar 

  6. Werner RM. The unintended consequences of publicly reporting quality information. JAMA. 2005;293:1239.

    Article  CAS  PubMed  Google Scholar 

  7. Colmers JM. Public reporting and transparency. Commonw Fund Comm a High Perform Heal Syst. 2007;1:1–16.

  8. Schneider E, Lieberman T. Publicly disclosed information about the quality of health care: response of the US public. Qual Health Care. 2001;10:96–103.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Berwick DM, James B, Coye MJ. Connections between quality measurement and improvement. Med Care. 2003;41:I30–8.

    Article  PubMed  Google Scholar 

  10. Hibbard JH, Stockard J, Tusler M. Hospital performance reports: impact on quality, market share, and reputation. Health Aff (Millwood). 2005;24:1150–60.

    Article  Google Scholar 

  11. Marshall JJ, Zoghbi WA, Gillis AM. Public reporting of cardiovascular care: an opportunity to shape the future. Catheter Cardiovasc Interv. 2013;81:403–6.

    Article  PubMed  Google Scholar 

  12. Brown DL, Clarke S, Oakley J. Cardiac surgeon report cards, referral for cardiac surgery, and the ethical responsibilities of cardiologists. J Am Coll Cardiol. 2012;59:2378–82.

    Article  PubMed  Google Scholar 

  13. Dehmer GJ, Drozda JP, Brindis RG, Masoudi FA, Rumsfeld JS, Slattery LE, Oetgen WJ. Public reporting of clinical quality data: An update for cardiovascular specialists. J Am Coll Cardiol. 2014;63:1239–45.

    Article  PubMed  Google Scholar 

  14. Hannan EL, Kumar D, Racz M, Siu AL, Chassin MR. New York State’s Cardiac Surgery Reporting System: four years later. Ann Thorac Surg. 1994;58:1852–7.

    Article  CAS  PubMed  Google Scholar 

  15. Mannion R, Goddard M. Impact of published clinical outcomes data: case study in NHS hospital trusts. BMJ. 2001;323:260–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, Guyatt GH. GRADE guidelines: 3. Rating the quality of evidence. Journal of Clinical Epidemiology. 2011;64:401–406.

  18. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88.

    Article  CAS  PubMed  Google Scholar 

  19. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–58.

    Article  PubMed  Google Scholar 

  20. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629–34.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Dziuban SW, McIlduff JB, Miller SJ, Dal Col RH. How a New York cardiac surgery program uses outcomes data. Ann Thorac Surg. 1994;58:1871–6.

    Article  PubMed  Google Scholar 

  22. Rosenthal GE, Quinn L, Harper DL. Declines in hospital mortality associated with a regional initiative to measure hospital performance. Am J Med Qual. 1997;12:103–12.

    Article  CAS  PubMed  Google Scholar 

  23. Peterson ED, DeLong ER, Jollis JG, Muhlbaier LH, Mark DB. The effects of New York’s bypass surgery provider profiling on access to care and patient outcomes in the elderly. J Am Coll Cardiol. 1998;32:993–9.

    Article  CAS  PubMed  Google Scholar 

  24. Baker DW, Einstadter D, Thomas CL, Husak SS, Gordon NH, Cebul RD. Mortality trends during a program that publicly reported hospital performance. Med Care. 2002;40:879–90.

    Article  PubMed  Google Scholar 

  25. Chassin MR. Achieving and sustaining improved quality: lessons from New York State and cardiac surgery. Health Aff (Millwood). 2002;21:40–51.

    Article  Google Scholar 

  26. Clough JD, Engler D, Snow R, Canuto PE. Lack of relationship between the Cleveland health quality choice project and decreased inpatient mortality in Cleveland. Am J Med Qual. 2002;17:47–55.

    Article  PubMed  Google Scholar 

  27. Baker DW, Einstadter D, Thomas C, Husak S, Gordon NH, Cebul RD. The effect of publicly reporting hospital performance on market share and risk-adjusted mortality at high-mortality hospitals. Med Care. 2003;41:729–40.

    PubMed  Google Scholar 

  28. Dranove D, Kessler D, McClellan M, Satterthwaite M. Is more information better? the effects of “report cards” on health care providers. J Polit Econ. 2003;111:555–88.

    Article  Google Scholar 

  29. Moscucci M, Eagle KA, Share D, Smith D, De Franco AC, O’Donnell M, Kline-Rogers E, Jani SM, Brown DL. Public reporting and case selection for percutaneous coronary interventions: an analysis from two large multicenter percutaneous coronary intervention databases. J Am Coll Cardiol. 2005;45:1759–65.

    Article  PubMed  Google Scholar 

  30. Carey JS, Danielsen B, Junod FL, Rossiter SJ, Stabile BE. The California Cardiac Surgery and Intervention Project: evolution of a public reporting program. Am Surg. 2006;72:978–83.

    PubMed  Google Scholar 

  31. Guru V, Fremes SE, Naylor CD, Austin PC, Shrive FM, Ghali WA, Tu JV. Public versus private institutional performance reporting: what is mandatory for quality improvement? Am Heart J. 2006;152:573–8.

    Article  PubMed  Google Scholar 

  32. Jha AK, Epstein AM. The predictive accuracy of the New York State coronary artery bypass surgery report-card system. Health Aff (Millwood). 2006;25:844–55.

    Article  Google Scholar 

  33. Hollenbeak CS, Gorton CP, Tabak YP, Jones JL, Milstein A, Johannes RS. Reductions in mortality associated with intensive public reporting of hospital outcomes. Am J Med Qual. 2008;23:279–86.

    Article  PubMed  Google Scholar 

  34. Friedberg MW, Mehrotra A, Linder JA. Reporting hospitals’ antibiotic timing in pneumonia: adverse consequences for patients? Am J Manag Care. 2009;15:137–44.

    PubMed  PubMed Central  Google Scholar 

  35. Ryan AM. Effects of the premier hospital quality incentive demonstration on medicare patient mortality and cost. Health Serv Res. 2009;44:821–42.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Li Z, Carlisle DM, Marcin JP, Castellanos LR, Romano PS, Young JN, Amsterdam EA. Impact of public reporting on access to coronary artery bypass surgery: the California Outcomes Reporting Program. Ann Thorac Surg. 2010;89:1131–8.

    Article  PubMed  Google Scholar 

  37. Werner RM, Bradlow ET. Public reporting on hospital process improvements is linked to better patient outcomes. Health Aff (Millwood). 2010;29:1319–24.

    Article  Google Scholar 

  38. Jha AK, Joynt KE, Orav EJ, Epstein AM. The long-term effect of premier pay for performance on patient outcomes. N Engl J Med. 2012;366:1606–15.

    Article  CAS  PubMed  Google Scholar 

  39. Joynt KE, Blumenthal DM, Orav EJ, Resnic FS, Jha AK. Association of public reporting for percutaneous coronary intervention with utilization and outcomes among Medicare beneficiaries with acute myocardial infarction. JAMA. 2012;308:1460–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Renzi C, Sorge C, Fusco D, Agabiti N, Davoli M, Perucci CA. Reporting of quality indicators and improvement in hospital performance: the P.Re.Val.E. Regional Outcome Evaluation Program. Health Serv Res. 2012;47:1880–901.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Ryan AM, Nallamothu BK, Dimick JB. Medicare’s public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions. Health Aff (Millwood). 2012;31:585–92.

    Article  Google Scholar 

  42. Linkin DR, Fishman NO, Shea JA, Yang W, Cary MS, Lautenbach E. Public reporting of hospital-acquired infections is not associated with improved processes or outcomes. Infect Control Hosp Epidemiol. 2013;34:844–6.

    Article  PubMed  PubMed Central  Google Scholar 

  43. McCabe JM, Joynt KE, Welt FGP, Resnic FS. Impact of public reporting and outlier status identification on percutaneous coronary intervention case selection in Massachusetts. JACC Cardiovasc Interv. 2013;6:625–30.

    Article  PubMed  Google Scholar 

  44. Marsteller JA, Hsu Y-J, Weeks K. Evaluating the impact of mandatory public reporting on participation and performance in a program to reduce central line-associated bloodstream infections: evidence from a national patient safety collaborative. Am J Infect Control. 2014;42(10 Suppl):S209–15.

    Article  PubMed  Google Scholar 

  45. Wang X, Tang Y, Zhang X, Yin X, Du X, Zhang X. Effect of publicly reporting performance data of medicine use on injection use: a quasi-experimental study. PLoS One. 2014;9:e109594.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Yang L, Liu C, Wang L, Yin X, Zhang X. Public reporting improves antibiotic prescribing for upper respiratory tract infections in primary care: a matched-pair cluster-randomized trial in China. Health Res Policy Syst. 2014;12:61.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Faber M, Bosch M, Wollersheim H, Leatherman S, Grol R. Public reporting in health care: how do consumers use quality-of-care information? A systematic review. Med Care. 2009;47:1–8.

    Article  PubMed  Google Scholar 

  48. Mannion R, Goddard M: Public disclosure of comparative clinical performance data: Lessons from the Scottish experience. Journal of Evaluation in Clinical Practice. 2003;9:277–286.

  49. Ledikwe JH, Grignon J, Lebelonyane R, Ludick S, Matshediso E, Sento BW, Sharma A, Semo BW. Improving the quality of health information: a qualitative assessment of data management and reporting systems in Botswana. Health Res Policy Syst. 2014;12:7.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Marshall MN, Shekelle PG, Leatherman S, Brook RH. The public release of performance data: what do we expect to gain? A review of the evidence. JAMA. 2000;283:1866–74.

    Article  CAS  PubMed  Google Scholar 

  51. Specchia ML, Veneziano MA, Cadeddu C, Ferriero AM, Capizzi S, Ricciardi W. Peer pressure and public reporting within healthcare setting: improving accountability and health care quality in hospitals. Ig Sanita Pubbl. 2012;68:771–80.

    PubMed  Google Scholar 

  52. Delnoij DM, Rademakers JJ, Groenewegen PP. The Dutch consumer quality index: an example of stakeholder involvement in indicator development. BMC Health Serv Res. 2010;10:88.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Büscher A. Public reporting, expert standards and indicators. Different routes to improve the quality of German long-term care. Eurohealth (Lond). 2010;16:4–7.

    Google Scholar 

  54. Rodrigues R, Trigg L, Schmidt AE, Leichsenring K. The public gets what the public wants: Experiences of public reporting in long-term care in Europe. Health Policy. 2014;116:84-94.

Download references


The work of Vladimir Vukovic was financially supported by the ERAWEB doctorate scholarship, under the European Commission. The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Authors’ contributions

MLS and PC designed the study under supervision of WR. PC, VV, PP and AS carried out databases search and VV and AS conducted data extraction. PC, VV and PP prepared the manuscript that was reviewed by MLS and WR. All authors approved the final version of the paper.

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

Being this article a systematic review, no data were directly collected from anyone (humans, animals, plants or bacteria). Ethical review board approval was therefore not required.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Paolo Campanella.

Additional file

Additional file 1:

Table reporting quality of the studies. (DOCX 58 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Campanella, P., Vukovic, V., Parente, P. et al. The impact of Public Reporting on clinical outcomes: a systematic review and meta-analysis. BMC Health Serv Res 16, 296 (2016).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: