This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cooley, D. A. Search for Related Content PubMed PubMed Citation Articles by Cooley, D. A.

(Circulation. 1996;93:1-3.)
© 1996 American Heart Association, Inc.

Articles

Building Shelters

Safeguards in Public Disclosure of Outcomes Data

Denton A. Cooley, MD

From the Department of Cardiovascular Surgery, Texas Heart Institute, Houston.

Correspondence to Denton A. Cooley, MD, Texas Heart Institute, PO Box 20345, Houston, TX 77225-0345.

Key Words: editorials • risk factors • mortality

	Introduction

Top Introduction References

 
The individuals which are best fitted for the complex, and, in the course of ages, changing conditions to which they are exposed, generally survive. . .

Charles Darwin

Nothing can escape the effects of evolution. Since the earth was formed, evolution has overpowered the strong, outrun the swift, and outwitted the wise. Every creature, from dinosaurs to human beings, has felt its influence. However, while other species have languished and disappeared, ours has flourished and endured. The secret to this success is not luck or circumstance but rather our ability to adapt to an ever-changing environment.

In this time of sweeping change, the medical profession must take the lessons of human evolution to heart. On the surface, the healthcare system in the United States seems to be "the best . . . in the world."¹ With only 5% of the world's population, we have received almost half of the Nobel prizes in medicine.² We also lead the world in medical innovation, training, and technology. However, while our system remains at the forefront in medical innovation, it lags behind the rest of the world in affordability.¹ To continue the tradition of excellence in American medicine, we must adapt to the changing medical climate. Health care must evolve.

Fortunately, we seem to be up to the challenge. Despite the failure of the Clinton plan, physicians have begun to work with insurers on necessary reform measures. This time, however, the movement toward reform is not driven by political rhetoric but rather by economic reality. Providers, payers, and patients alike recognize that something must be done, and soon. The question is what?

Public disclosure of hospital- and surgeon-specific outcomes has become the latest hot-button issue in healthcare reform. The editor of the New England Journal of Medicine called it "the third revolution in medical care."³ In the past, the American public regarded medicine and her providers with awe; today that awe has been replaced with suspicion. Patients no longer assume that they will receive quality care. Instead, they demand the same hard data from providers that they would from a car or computer company. They demand, in essence, a medical version of Consumer's Digest.

Public disclosure initiatives have singled out cardiac surgery for particular scrutiny, especially coronary artery bypass graft surgery (CABG). To many people, CABG exemplifies the bloat and excess of our healthcare system. Business Week estimated that up to 44% of CABG procedures are "of doubtful value."⁴ Critics of CABG and other treatments for myocardial ischemia believe that the benefits of procedures like CABG do not outweigh its costs and are demanding data to justify their use. Thus, the Health Care Financing Administration⁵ and the states of New York⁶ and Pennsylvania⁷ have all collected data on mortality rates for CABG, both for hospitals and for individual physicians. Despite debates about the accuracy of these data, managed care organizations often use them to make decisions for their members.

In a managed care system, "health care decisions are made on the basis of cost and quality information."⁸ Thus, information could be called the currency of managed care.⁹ Public disclosure data distinguish providers with good outcome rates from others competing for managed care contracts. In turn, managed care networks can use outcome rates to determine which providers will give them what they believe to be the greatest value for their money. For this reason, managed care networks and other payers are lobbying for increased public disclosure of outcome rates.

The first issue that must be addressed in any discussion of public disclosure is the accuracy of risk-adjusted mortality rates.¹⁰ Risk adjustment is still in its earliest stage of development, and risk-adjusted outcome rates are still highly inaccurate. In fact, our ability to adjust mortality rates for risk is somewhat comparable to our ability to treat infection before the advent of penicillin. Generally, the models of risk adjustment available today can only be used to identify either exceedingly excellent or exceedingly poor care. In addition, different studies have used different models of risk adjustment, so the results of these studies cannot be compared. Thus, as the use of outcome rates spreads, a national model for determining risk-adjusted mortality rates must be devised and implemented as soon as possible.

The ultimate effects of public disclosure are unknown.¹¹ In this issue of Circulation, Omoigui et al¹² attempt to explain part of the 41% drop in risk-adjusted mortality associated with isolated CABG in New York State patients. They report that outmigration of patients to the Cleveland Clinic has increased significantly since the New York Department of Health began collecting surgeon- and hospital-specific data on CABG. There are several possible causes for this phenomenon. Physicians at community hospitals may be reluctant to accept high-risk patients for fear of lowering their outcome rates. Fear of lower outcome rates may also be discouraging hospitals from admitting high-risk patients. Finally, the high mortality rates at some local hospitals may prompt the patients themselves to seek treatment elsewhere. For whichever reason that outmigration is occurring, however, public disclosure is certain to produce a lasting impact on our healthcare system.

Public disclosure could produce some positive results. Fear of poor outcome rates may motivate hospitals and physicians to root out inefficiencies in their systems, thereby reducing the number of preventable deaths. This phenomenon has already occurred in many New York State hospitals. Hannan et al¹³ report that the largest drop in mortality rates among New York cardiac surgeons occurred in the group with the highest previous mortality rates. Thus, while public disclosure will not improve the quality of care a patient receives from an already excellent provider, it may help raise the standards of less conscientious providers.

Public disclosure of outcomes may also encourage surgeons in community-based hospitals to send high-risk patients to tertiary care centers. In the past, some surgeons may have avoided sending complex cases to such centers, preferring instead to perform the surgery themselves. Under public disclosure, however, performing such surgery could result in a higher reported mortality rate. Thus, community-based surgeons may choose to send patients to the hospital that can provide the best care.

Patients themselves may be more likely to seek treatment at tertiary centers if the outcome rates of their local hospitals are poor. This effect may ultimately benefit the patient, since tertiary care centers can provide the latest in medical knowledge and innovation as well as the advantages that come with experience. Thus, quality of care may improve as a direct result of outmigration.

Outmigration will also produce some negative effects. Because of a higher than usual influx of high-risk patients, tertiary care hospitals may see a corresponding increase in their mortality rates. Already, the Texas Heart Institute has seen a modest increase in the mortality rates for certain procedures.¹⁴ Because of such increases, future high-risk patients may opt (or return) to seek care in community hospitals.

Academic centers can ill afford such a decrease in patient base. Already, the higher fees charged by some tertiary care centers have alienated many managed care networks, which are not interested in the community services supported by these institutions (eg, teaching and research). Less favorable outcome rates may further deter managed care networks from sending their patients to these centers.

Public disclosure also subjects hospitals and surgeons to increased media exposure. At a time when sensational trials and television talk shows are glutting the airwaves, news programs must fight to maintain a viewership. To do so, such programs often resort to tabloid journalism. In 1993, PrimeTime Live¹⁵ exposed what they called a "cover-up" at a cytology laboratory in Newport, RI. Although the laboratory did make some mistakes, the program exaggerated their degree. In addition, the press failed to inform the public that (1) there is always some margin of error in Pap smear screening and (2) the mistakes reported were made before a new director had revamped the facility. Besides costing the laboratory money and bad publicity, the program spread fear among women whose Pap smears had been screened there. As is evident in such a case, media exposure often promotes "fear and anger rather than education, a fair hearing, and understanding."¹⁵

In considering public disclosure of outcome rates, we must remember that the practice of medicine is not a precise art. Unlike a car or a computer, people are living, breathing creatures whose conditions cannot always be predicted, even by their physicians. While public disclosure may help prevent wanton medical abuses, we must not become dependent on statistics to determine excellence of care.

Our prime duty as physicians is to relieve suffering and improve the quality and length of life of our patients. Thus, physicians must not base their decisions on how their actions will affect their outcome rates but rather on how their actions will affect their patients. Widespread use of outcome rates is inevitable. Although there are several disadvantages to such a system of public disclosure, its coming is as inexorable as the tide. Whereas we do not have the power to stop healthcare reform (nor should we), we do have the power to maneuver within its parameters (eg, to develop an accurate method of determining risk-adjusted mortality rates). Consider our ancestors: although they could not stop the approach of winter, they learned to build shelters to withstand the bitter cold. We must build our own shelters: as healthcare providers, we must develop reform measures that will not deter the physician from performing his duty as patient advocate and that will not stifle progress or limit the application of already proven treatments. As Reinhold Niebuhr once said, we must have "the grace to accept with serenity the things that cannot be changed, courage to change the things that should be changed, and the wisdom to distinguish the one from the other."

	Footnotes

 
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

	References

Top Introduction References

 

1. Fuchs VR. The best health care system in the world? JAMA. 1992;268:916-918. [Medline] [Order article via Infotrieve]
   
2. Sullivan LW. The Bush administration's health care plan. N Engl J Med. 1992;327:801-804. [Medline] [Order article via Infotrieve]
   
3. Relman AS. Assessment and accountability: the third revolution in medical care. N Engl J Med. 1988;319:1220-1222. [Medline] [Order article via Infotrieve]
   
4. McNamee M. When less is more in coronary care. Business Week. October 3, 1994:60.
   
5. Health Care Financing Administration. Medicare Hospital Mortality Information, 1987, 1988, 1989. Washington, DC: US Department of Health and Human Services; 1990. HCFA publication 0074.
   
6. Hannan EL, Kilburn H, Racz M, Shields S, Chassin MR. Improving the outcomes of coronary artery bypass surgery in New York State. JAMA. 1994;271:761-766. [Abstract]
   
7. A Consumer Guide to Coronary Artery Bypass Graft Surgery. Harrisburg, Pa: The Pennsylvania Health Care Cost Containment Council; 1992.
   
8. Lipson EH. What are purchasers looking for in managed care quality? Top Health Care Financ. 1993;20:1-9.
   
9. Denton DA, Chaux A, Matloff JM. A cardiothoracic surgery information system for the next century: implications for managed care. Ann Thorac Surg. 1995;59:486-493. [Abstract/Free Full Text]
   
10. Kassirer JP. The quality of care and the quality of measuring it. N Engl J Med. 1993;329:1263-1265. [Free Full Text]
    
11. Iezzoni LI. Using risk-adjusted outcomes to assess clinical practice: an overview of issues pertaining to risk adjustment. Ann Thorac Surg. 1994;58:1822-1826. [Abstract]
    
12. Omoigui NA, Miller DP, Brown KJ, Annan K, Cosgrove D III, Lytle B, Loop F, Topol EJ. Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes. Circulation. 1996;93:27-33. [Abstract/Free Full Text]
    
13. Hannan EL, Kumar K, Racz M, Siu AL, Chassin MR. New York State's Cardiac Surgery Reporting System: four years later. Ann Thorac Surg. 1994;58:1852-1857. [Abstract]
    
14. Alexander WA, Keats AS. Validation of the Society of Thoracic Surgeons (STS) National Cardiac Surgery Database (NCSD) utilizing a single institutional model of CABG outcomes. Circulation. 1994;90(pt 2):II-529. Abstract.
    
15. Wang SE. The consequences of public disclosure: an opinion from Newport Hospital, Newport, RI. Diagn Cytopathol. 1994;11:211-212.[Medline] [Order article via Infotrieve]
    

This article has been cited by other articles:

				D. M. Shahian, S.-L. Normand, D. F. Torchiana, S. M. Lewis, J. O. Pastore, R. E. Kuntz, and P. I. Dreyer Cardiac surgery report cards: comprehensive review and statistical critique Ann. Thorac. Surg., December 1, 2001; 72(6): 2155 - 2168. [Abstract] [Full Text] [PDF]

				A. H. Hamawy, L. Y. Lee, S. A. Samy, D. R. Polce, M. Szulc, M. Vazquez, and T. K. Rosengart Transmyocardial laser revascularization dose response: enhanced perfusion in a porcine ischemia model as a function of channel density Ann. Thorac. Surg., September 1, 2001; 72(3): 817 - 822. [Abstract] [Full Text] [PDF]

				E. D. Peterson, E. R. DeLong, L. H. Muhlbaier, A. B. Rosen, H. E. Buell, C. I. Kiefe, and T. F. Kresowik Challenges in comparing risk-adjusted bypass surgery mortality results: Results from the Cooperative Cardiovascular Project J. Am. Coll. Cardiol., December 1, 2000; 36(7): 2174 - 2184. [Abstract] [Full Text] [PDF]

				CABG ``Report Cards'' Shifting Sicker Patients Elsewhere? Journal Watch Cardiology, March 1, 1996; 1996(301): 13 - 13. [Full Text]

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cooley, D. A. Search for Related Content PubMed PubMed Citation Articles by Cooley, D. A.