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(Circulation. 1999;99:2067-2069.)
© 1999 American Heart Association, Inc.

Editorials

Mathematical Models and the Assessment of Performance in Cardiology

Harlan M. Krumholz, MD

From the Section of Cardiovascular Medicine, Department of Medicine, and the Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn; the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Conn; and Qualidigm, Middletown, Conn.

Key Words: Editorials • risk factors • bypass

We have entered a new era of medicine, in which physicians are no longer granted an assumption of excellence. Studies have demonstrated marked variability in the practice of medicine¹ and revealed abundant opportunities for improvement in the care of patients. These studies have accentuated the pressure exerted by payers and the public on the profession to assume greater responsibility for delivering high-quality care.

In this era of accountability, ratings and rankings proliferate as the public and payers seek information about the performance of physicians, hospitals, and health plans. The consequences of these rankings can be profound as marketing departments and the popular press seize the results. Hospitals ranked highly tend to tout their status in advertisements, whereas those with less favorable ratings hope to avoid being identified as hazards.

The interest in rankings is particularly strong in cardiovascular medicine. Cardiovascular diagnoses represent a substantial proportion of high-volume and high-cost admissions to hospitals. Statewide and national efforts have focused on institution- and physician-specific outcomes after cardiovascular procedures and acute myocardial infarction.^{2 3} In several areas, such as bypass surgery, mortality rates are the most common basis for quality-of-care rankings. In New York, bypass surgery ratings of individual surgeons based on mortality rates⁴ are highly publicized in the press. Studies suggest that these public ratings have stimulated improvements in the care and outcomes of patients, although the evidence is indirect.⁵

Because patients are not randomly allocated to different physicians or hospitals, the comparison of outcomes among various sites is challenging. Differences in referral . . . [Full Text of this Article]

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