Over the past few decades, public reporting of health providers’ performance (PRHPP) has been increasingly used for the purpose of improving the quality of patient care (Marshall et al., 2000). It started in the United States in the 1980s (Hannan et al., 1994) and has since been adopted by many other developed countries (Hibbard et al., 2003; Marshall et al., 2003). PRHPP is considered as an instrument that can improve the quality of care through enhancing transparency and accountability (Lansky, 2002; Hibbard et al., 2003; Fung et al., 2008). It is expected that patients use the information to choose healthcare providers, which would force healthcare providers to improve their underperforming areas in order to maintain their market share (Berwick et al., 2003; Asch et al., 2006; Fung et al., 2008).

Empirical studies showed that patients are interested in information related to quality of care (Longo and Everet, 2003; Boscarino and Adams, 2004; Cheng and Song, 2004; Sofaer et al., 2005), and nearly 50% consider quality as the most important aspect when choosing a healthcare provider (Robinson and Brodie, 1997; Schneider and Epstein, 1998). However, evidence about the association between PRHPP and patient choices has been inconclusive (Faber et al., 2009; Totten et al., 2012).

It is not clear how patients value and use PRHPP (Marshall et al., 2000; Werner and Asch, 2005; Faber et al., 2009). Hibbard and others proposed a theory of the consumer choice model (CCM), which assumes that the impacts of PRHPP take place through four stages in a sequential order (Hibbard et al., 2002). At the first stage, patients become aware of the PRHPP. Gradually, they develop an appropriate understanding of the information involved in the PRHPP (stage two). But before they use PRHPP as an instrument for choosing healthcare providers (stage four), they have to develop an appreciation of the value of PRHPP (stage three). The perceived value of PRHPP is critical and subject to the influences of both personal and environmental factors, such as the characteristics of patients, the interactive dynamic between patients and healthcare providers, and the healthcare system arrangements.

Faber and others, in a systematic review, identified the lack of understanding of the staged effects of PRHPP on patients as a gap in the literature that deserves attention (Faber et al., 2009). Several studies attempted to understand how patients might use PRHPP in simulated environments (Hibbard et al., 1996; Hibbard et al., 2000; Hibbard et al., 2001a; Uhrig et al., 2006; Peters et al., 2007). A few researchers observed how healthy consumers chose a new health plan using reported performance information on various plans (Knutson et al., 1998; Farley et al., 2002a; Farley et al., 2002b; Hibbard et al., 2002). But there is a paucity in the literature documenting how patients choose a provider when they are ill. In addition, all of the existing studies have been conducted in the USA (Faber et al., 2009). Little is known about the effects of PRHPP in other countries, especially in developing countries.

In this study, we applied the propensity score method (PSM) to estimate the effects of PRHPP on patient changes in line with the CCM theory in Hubei province, China. PSM has been increasingly used in health services research (Austin, 2008), which allows us to estimate causal effects based on cross-sectional data (Caliendo and Kopeinig, 2008).

This study was undertaken in 10 primary care institutions in Qianjiang city in China’s Hubei province. A cross-sectional questionnaire survey was conducted on patients who visited the participating institutions, 10 months after PRHPP interventions were introduced.

This study revealed that PRHPP can improve patient understanding about the prescribing performance information, but it failed to translate into a useful tool to help patients make choices. Previous studies also showed no or weak evidence to support the link between PRHPP and patient choices in real world contexts (Faber et al., 2009; Totten et al., 2012), despite strong evidence supporting such a link in an experimental environment.

PRHPP serves as one way to inform consumer healthcare choices by comparing physicians’ performance of various dimensions of quality and cost. PRHPP practice in this study covered the core prescribing indicators of percentage of prescriptions requiring antibiotics, percentage of prescriptions requiring injection and cost indictor of average expenditure of patients. WHO in collaboration with the International Network of Rational Medicine Use (INRDU) recommended the set of core prescribing indictors, which have been widely applied for evaluating antibiotic prescribing quality among primary healthcare facilities in developing countries (Aravamuthan et al., 2017; Amaha et al., 2019; Kilipamwambu et al., 2021).

Based on the results from a recent review, public reporting of physicians’ and hospitals’ performance can help stimulate quality improvement, inform consumer choices and ultimately improve clinical results moderately. For consumers, with transparent and easily available performance information, PRHPP could help facilitate consumers to select a physician or medical institutions that appeared to have better results (Prang et al., 2021). However, whether PRHPP works or how the amount of practical effects depended on a list of various factors, such as the appropriateness of disseminated channel of PRHPP, relevance and meaningfulness of the chosen indictors, and consumer characteristics, which are discussed below for the limited effects of PRHRR in this study (Hibbard and Sofaer, 2010).

The CCM theory postulates a staged process for behavioral changes. It is essential to make sure that the reported information is valuable from the perspective of consumers before they are willing to use the information for decision making. Although in this study, participants enjoyed the freedom to choose providers, they might not necessarily appreciate the value of the PRHPP information for several reasons.

Firstly, the overuse of antibiotic and injection prescriptions is common and consistently high in primary care institutions and prescription costs have already been lowered due to the recent health system reform in China. Empirical studies show that PRHPP is more useful for patients when obvious differences in provider behaviors are observable (Harris, 2002). Otherwise, little value would be perceived by patients in relation to changing providers. Indeed, the percentage of prescriptions requiring antibiotics or injections are overwhelmingly high in China (Liu et al., 2015). Despite strong government interventions to tackle this problem, there has been no sign of decline in antibiotic and injection prescriptions (Li, 2014; Liu et al., 2015; Liu et al., 2016). In the participating institutions of this study, no prescriber was able to meet the WHO recommendations in relation to of the rational use of medicines (Laing et al., 1993).

Secondly, consumer demand for antibiotics and injections are high. In China, many patients believe that antibiotics and injections are a shortcut to quick recovery from many illnesses, including common colds (Wei et al., 2006). Such a misunderstanding may seriously jeopardize the value of PRHPP (Baker et al., 2014; Spaling et al., 2015; Dodds et al., 2016). The misconception could negatively affect the perception of the raking indictors of PRHPP practice. It was likely that PRHPP may lead more patients to seek services from those doctors prescribed more antibiotics and injections. Numerous studies have demonstrated that a lack of appropriate understanding is a major barrier preventing patients from using PRHPP information (Hibbard and Jewett, 1996; Jewett and Hibbard, 1996; Boscarino and Adams, 2004; Richard et al., 2005; Sofaer et al., 2005; Robinowitz and Dudley, 2006). Although we found significant improvement in patient understanding of the PRHPP information, such improvement is limited. Some researchers recommend simplified presentations such as a star rating to improve understanding and endorsement from patients (Peters et al., 2007; Damman et al., 2012).

Thirdly, the disclosed information may not be considered relevant to the priorities of the patients. Patients are more likely to appreciate the information that fits better with their needs. For example, cancer patients would need quite different information compared to diabetic patients (Edgman-Levitan and Cleary, 1996). Unfortunately, we were not able to collect diagnostic information because more than half of the questionnaires were collected prior to medical consultations.

Finally, the level of patient awareness of the PRHPP is low. Only one-fifth of the respondents reported being aware of the PRHPP. This rate is much lower compared with those (49%–78%) found in studies conducted in the USA (Knutson et al., 1998; Farley et al., 2002a; Hibbard et al., 2002). However, it is important to acknowledge that these studies offered participants a choice of a healthcare plan which is relevant to almost everyone (Knutson et al., 1998; Farley et al., 2002a; Farley et al., 2002b; Hibbard et al., 2002). For information related to patient care interventions, however, it is challenging to attempt to attract attention from all patients. Some researchers argued that patients with different illness conditions may have very different preferences in the choice of medical interventions. The rationale behind their choices could not be understood through observations of choices made by healthy people (Faber et al., 2009). Schneider and Epstein reported that only 12% of hospital patients who underwent coronary artery bypass grafting (CABG) surgery paid attention to reported CABG mortality rates (Schneider and Epstein, 1998). It is not clear why so many CABG patients ignored the reported mortality information.

A lack of understanding and support from patients for the rational use of medicines is a serious issue of concern. The overuse of antibiotics and injections is very common in China and many other developing countries. It has contributed to the rapid spread of antibiotic resistance (Robinowitz and Dudley, 2006), transmission of the human immunodeficiency virus and hepatitis B virus (Damman et al., 2012), and escalation of medical costs.

PRHPP is intended to be an instrument for empowering patients. However, careful design of the PRHPP is essential to obtain endorsement from patients. A number of guidelines are available for developing a readable and understandable PRHPP (Drozda et al., 2008; Hussey et al., 2014).

New approaches should be developed to solve the effectiveness of PRHPP practice, such as engagement of professional societies, increasing disseminating channel of public information, determining the best format for presentation of information to consumers, and eliminating the misconceptions of the information by consumers (Dehmer et al., 2014). The engagement of professional societies has been mentioned as one effective way for developing meaningful performance measures and promoting use of public reporting. Increasing the disseminating channel is also identified as one effective strategy, for example, information can be reported through a range of media, such as individual reminders, educational materials, public forums, clinical audits and feedback (Grimshaw et al., 2004). Research evidence shows that explanatory messages are not effective in correcting misconceptions and in increasing the perceived value of PRHPP (Hibbard et al., 2000). A simple message about risks may be more effective. A study conducted in India suggests that information disseminated from physicians is more effective than public reporting, resulting in lower injection use (Bhunia et al., 2010), possibly because the information targeted those with the highest risk. General education of the public plays an important role in the effectiveness of PRHPP. Low levels of education and socioeconomic status are usually associated with low awareness and poor understanding of PRHPP (Hibbard et al., 2001b). The average level of education and income of the participants of this study was low, which might have contributed to the limited effects of the PRHPP.

The effects of PRHPP should be explained with caution. The effects of the PRHPP, both positive and negative, are context dependent. In this study, three prescription indicators were reported in line with the WHO recommendations (Laing et al., 1993). Similar to the findings of other studies (Robinson and Brodie, 1997; Schneider and Epstein, 1998), these three indicators did not attract equal attention from patients: patients are more concerned about the quality rather than the cost of prescriptions. However, given the prevalent misconception about antibiotic and injection interventions from consumers, there is a risk that PRHPP may encourage more patients to seek services from those doctors who are more likely to prescribe antibiotics and injections. In addition, the doctors who rank low in the league table may choose to increase antibiotic and injection prescriptions in order to increase their market share (Wang et al., 2014). Some researchers worry that the reported poor performance of health workers may exacerbate the existing strained relationship between physicians and patients in China (Tang et al., 2008), stimulating distrust and more defensive practices (Totten et al., 2012). Further studies are needed to tap into these questions.

This study has made a significant contribution to the literature by applying CCM theory to explore the effects of PRHPP in a real-world context. The SEM analysis showed that the CCM theory fits well with the data. The application of PSM reduced potential bias in estimating the effect size of the PRHPP (Li, 2013).

Patient awareness of the PRHPP is low. The effects of the PRHPP are limited, with some improvement of patient understanding about the antibiotic and injection prescription indicators. The PRHPP failed to show significant impacts on patient perceived value and use of information. The healthcare system contexts and low socio-economic status of the participants may be associated with the limited effects of the PRHPP. Appropriate patient education and provider training are prerequisites for the introduction of PRHPP programs.