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Variation in patient management and cardiovascular outcomes occurs at all levels of the healthcare system and is itself a measure of care quality. However, in focusing on management and outcomes it is easy to overlook service quality as it affects the patient experience of hospital care. Service quality is now a major preoccupation of the UK’s nationalized health system where a new payments framework encourages care providers to continually improve how care is delivered. Limits have been placed on waiting times for outpatient appointments, diagnostic tests and treatment within the emergency department. If these limits are breached the offending hospitals face punitive financial penalties. Cancellation of urgent surgery and MRSA carry yet greater penalties. In this way poorly performing hospitals are forced to improve the service they deliver or face financial ruin.

Other paymasters apart from central government purchase clinical care from hospitals and they too are flexing their financial muscle. Thus, valuable cardiovascular treatment contracts are shared out between different local cardiac departments according to management and outcome data published in the UK’s national registries.  Door to balloon times benchmarked against national averages, for example, are a widely used performance indicator of the management of acute myocardial infarction (AMI), as are prescription rates for secondary prevention drugs. Attention now, however, is shifting away from process measures to outcomes and 30-day AMI mortality data for every UK hospital is now publicly available in the world-wide web. Attempts to rank hospitals by these metrics have been fraught with difficulty but recent scandals of under-performing hospitals have driven calls for the naming and shaming of statistical outsiders in an attempt to protect patients from substandard care. This “transparency agenda” at the hospital level has now moved on to include outcome reporting for individual operators. Doctors and their patients can now consult their web-browser to find the operative mortality of local cardiac surgeons and interventionists in order to inform referral decisions.

What of the future? I have two predictions to offer you. 1) Local benchmarking is likely to cross national boundaries and already there have been a number of international comparisons highlighting management-related differences in cardiovascular outcomes.  2) The patient voice will get louder and patient reported outcome measures will become the main performance indicator of interest.