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Outcome transparency and its effects on quality of hospital care



The German medical and patient community is witnessing an intensified political, regulatory, payer/provider and third party movement to release health care outcome data into the public domain. The resulting transparency is supposed to remedy information asymmetries in health care markets, enabling consumers to choose high quality health care providers and allowing physicians a clear assessment of their own performance relative to others and standard medical practice.

At the same time, controversies around outcome transparency and demands for risk adjustment of available data have increased. Many physicians and hospital administrators criticize the increased resource use associated with outcome measurement and point to unfair treatment of hospitals with more severe cases and higher levels of comorbidity. Likewise, many physicians and researchers point to the scant empirical evidence that outcome measurement and transparency actually improve medical outcomes over time.

In fact, the existing academic literature presents mixed results in magnitude, direction and statistical significance. These mixed results can partly be explained by different research designs and the often imperfect outcome data available for academic analysis. The question whether outcome transparency actually improves quality of care remains to be answered. In addition, most existing research focuses on US and British data (e.g. CABG surgery data from New York State and Pennsylvania and the NHS). Consequently, there is a clear need to reexamine and clarify the effect of increased outcome transparency on quality of care and expand the scope of empirical analysis beyond the Anglo-American context to other geographies.


Current German landscape of outcome transparency

In Germany, several outcome measurement initiatives exist in parallel. On the one hand, all German hospitals have to submit structural and outcome data to a nationwide mandatory benchmarking database managed by the Gemeinsamer Bundesausschuss (G-BA). This data today includes 290 publicized process and outcome indicators across 30 treatment areas and provides the underlying data for outcome reporting on many payer websites and the Whitelist, a non-partisan online tool to support patients´ hospital choice.

At the same time, two further, “next generation” outcome transparency initiatives – the Initiative Qualitätsmedizin (IQM) and the Qualitätssicherung mit Routinedaten (QSR) - leverage the detailed administrative data collected as part of the DRG reimbursement process at the hospital and payer level to publish outcome measures across key treatment areas and long-term performance measures across the full care cycle. The IQM member hospitals publish their outcome data on their own websites and the QSR underpins the outcome reporting in the AOK Hospital Navigator.

Lastly, some medical societies and smaller research institutes, such as the German Cancer Society and the An-Institute for Quality Assurance in Operative Medicine, collect outcome measures in certain medical specialty areas. This data is often not publicized, but used for certification purposes or looped back to partaking hospital and medical departments for process improvement.


The project

The German Federal Ministry of Health is building a new institute for quality assurance and transparency in health care to be in operation by 2016, with the goals to synthesize the different approaches to quality measurement, to further develop indicators for intersectoral quality measurement and to publish patient-friendly comparisons of hospital quality. Simultaneously, German payers would like to increase their focus on financial quality incentives in their reimbursement processes, e.g. through selective provider contracting based on outcomes.

To inform these quality improvement initiatives as well as expand and solidify the existing literature, this research project examines:

  1. International comparasion of outcome transparancy: Measuring, Reporting, and Rewarding Quality of Care
  2. Evolution of quality of care: depicting the development of quality of care in Germany after introduction of outcome measurement and the evolution of the German outcome transparency landscape
  3. The link between outcome transparency and quality improvement: Examining the causal link between outcome measurement/transparency and improvements in provider quality of care and the influencers of that relationship
  4. Outcome transparency and competition: the effects of quality leadership on market share of hospitals

As an empirical foundation for the project, we construct an extensive panel data set including structural and outcome data at the hospital and department level between the years of 2006-2013. Firstly, the database integrates publicly available German hospital quality reports from the Gemeinsamer Bundesausschuss (G-BA). Secondly, we include selected outcome indicators from the Qualitätssicherung mit Routinedaten (QSR) to enhance data validity and scope of treatment areas covered and to expand outcome indicators beyond in-patient care to cover the full care cycle. Lastly, we include additional variables such as hospital certification status, hospital service type and information on the competitive environment of hospitals (AOK Hospital Directory).


Associated partners


This project is funded by the German Research Foundation [Deutsche Forschungsgemeinschaft] (DFG) an supported by numerous partners:



Pross C, Geissler A, Busse R (2017): Measuring, Reporting, and Rewarding Quality of Care in 5 Nations: 5 Policy Levers to Enhance Hospital Quality Accountability. The Milbank Quarterly, 95: 136–183. doi: 10.1111/1468-0009.12248

Pross C, Averdunk LH, Stjepanovic J, Busse R, Geissler A (2017): Health care public reporting utilization - user clusters, web trails, and usage barriers on Germany’s public reporting portal Weisse-Liste.de. BMC Medical Informatics and Decision Making, 17:48. doi: 10.1186/s12911-017-0440-6

Pross C, Busse R, Geissler A (2017): Hospital quality variation matters – A time-trend and cross-section analysis of outcomes in German hospitals from 2006 to 2014. Health Policy, 121(8): 842-852. doi: 10.1016/j.healthpol.2017.06.009

Pross C, Strumann C, Geissler A, Herwartz H, Klein N (2018): Quality and resource efficiency in hospital service provision: A geoadditive stochastic frontier analysis of stroke quality of care in Germany. PLOS ONE 13(9): e0203017. doi: 10.1371/journal.pone.0203017

Pross C, Schöner L, Geissler A, Busse R (2021): Qualitätstransparenz im Gesundheitswesen: eine gesundheitsökonomische Modellbetrachtung. Gesundheitsökonomie & Qualitätsmanagement 2021; 26(05): 276-282. doi: 10.1055/a-1543-4831



Pross C: Review on quality transparency: Measuring, reporting and rewarding quality of hospital care in five nations. European Health Economics Association (EuHEA) Conference, Hamburg, Juli 2016

Pross C: Hospital choice matters: A 2006–2014 time-trend analysis of outcome variation in German hospitals. European Public Health Conference, Wien, November 2016

Geissler A: User clusters, click streams and barriers on Germany`s public reporting portal Weisse Liste.de. European Public Health Conference, Wien, November 2016

Pross C: The choice of a hospital is crucial: A mixed-method analysis of outcome quality and their variation in Germany between 2006-2014 [Die Wahl des Krankenhauses ist entscheidend: eine Mixed-Method-Analyse von Ergebnisqualität und deren Variation in Deutschland zwischen 2006-2014]. Armut und Gesundheit, Berlin, März 2017

Geissler A: Use of quality data in Germany: Analysis of the user data of the portal Weisse Liste.de [Nutzung von Qualitätsdaten in Deutschland: eine Untersuchung der Nutzerdaten des Portals Weisse Liste.de]. Armut und Gesundheit, Berlin, März 2017

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Lukas Schöner


Hanna Tratz
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