A recent study published in the Journal of the American College of Cardiology (June 7, 2005) gives evidence that doctors practicing in states that require the public reporting of patient-outcomes data are holding back potentially life-saving medical care from patients who are at high risk. The reporting of such outcomes data, both for individual doctors and for hospitals, is required in several states, and is widely regarded as a means of improving the quality of medical care.
The authors of this study compared the use of angioplasty and stenting for coronary artery disease in Michigan (a state that does not mandate outcomes reporting) and in New York (which does mandate reporting.) They examined which types of patients were treated, why they were treated, and the incidence of death following the cardiac procedures. They found that patients having coronary artery intervention in Michigan, on average, were significantly higher-risk patients than those in New York. Accordingly, the rate of mortality following treatment was higher in Michigan - but when the data was recalculated to account for the higher risk of the Michigan patients, the mortality rates between Michigan and New York were equivalent.
Thus, while the actual performance of doctors in New York and Michigan appeared to be equivalent, it appears that doctors and hospitals in New York are optimizing their outcomes data by avoiding coronary artery interventions in the highest-risk patients.
DrRich Comments:
In an editorial that accompanies this article, Dr. Zoltan Turi notes that public reporting of outcomes data has had many benefits since it came into use in the early 1990s. Part of this benefit is the result of more intensive quality control measures, measures that were triggered by an awareness that the public was watching.
Another part of the benefit is that some doctors and surgeons have been forced out of business based on their publicly-revealed mortality rates.
This latter sort of "benefit" has not escaped the notice of the surviving cardiologists, who, being human and therefore subject to human nature, have taken steps to avoid similar fates. The obvious step is simply to avoid performing these interventional cardiac procedures on patients who are at the highest risk - and therefore are more likely to die - even if the potential benefit to them from these procedures is also high. Indeed, notes Turi, agreeing to treat such a patient in this environment "takes a particular blend of personal courage".
For the type of high-risk patient we are talking about, the risk of mortality without the cardiac procedure is quite high; it is also high - though measurably lower - if the procedure were to be done. So either way, there is a substantial risk of death. But when the doctor declines to do the procedure, at least the death isn't going to be publicly attributed directly to him/her.
The payers certainly endorse these results, since now the patients who are reasonably likely to die anyway are doing so without the added expense of coronary artery intervention. Payers get to tout their quality-improvement measures, not to mention their championing of the public's right to know, and also to save a bunch of money besides.
What about the patients themselves? "Normal-risk" cardiac patients may be marginally better off in New York, since the some docs and hospitals with sub-par results are less likely to still be providing these medical services. But if I'm high-risk, I'm considering relocating to Michigan.
