The influence of public reporting of outcome data on medical decision making by physicians

1. The influence of public reporting of outcome data on medical decision making by physicians Paul Barach, MD, MPH UMC U

2. May 29, 2006

3. Variation in death rates and charges in US hospitals

4. Variation in CABG rates per 1000 Medicare Enrollees

5. May 1, 2006

6. Average rate per exposure of catastrophes and associated deaths in various industries and human activities From: Amalberti R., Barach P: 5 System barriers to achieving ultra-safe health care. Ann Intern Med. 2005;142:756-764.

7. “A single death is a tragedy, a million deaths is a statistic” Joseph Stalin’s comment to Winston Churchill at the Potsdam Conference, 1944

9. Mr. Altman’s New York Times article stated the following: “The hospital where former President Bill Clinton awaits bypass surgery has the highest death rate for the operation in New York State, according to the state’s Health Department. While the death rate is quite low—fewer than 4% of all bypass operations—it is still nearly double the average for hospitals in the state that perform bypasses … . Columbia Presbyterian and Westchester Medical Center were the only two hospitals in the state that had risk-adjusted death rates that were significantly higher than the statewide rate.”

10. The influence of public reporting of outcome data on medical decision making by physiciansC.R. Narins, A.M. Dozier and F.S. LingArch Intern Med 2005;165:83–7.The majority of respondents (76%) disagreed or strongly disagreed that public reporting of outcome data serves to improve patient care in New York State. Of those who responded, 79% agreed or strongly agreed that the publication of outcome data influenced their decision to intervene on critically ill patients such as those with cardiogenic shock, 83% agreed that patients who might benefit from angioplasty may not receive the procedure as a result of public reporting of physician-specific mortality rates. In addition, 85% disagreed or strongly disagreed with the statement that risk adjustment is adequate to avoid punishing the physician who performs high-risk procedures.

11. The Big Chill The Deleterious Effects of Public Reporting on Access to Health Care for the Sickest Patients, Zoltan G. Turi MD, , FACC; JACC 2005Why is the mortality going down?The four hypotheses are: 1) improvements in periprocedural management, 2) changes in patient selection, 3) aggressive assignment of variables that define patient risk, and 4) migration of high-risk patients to nonreporting states.

12. In states that have adopted public reporting, it takes a particularly blend of personal courage to perform PCI on the highest-risk patients. While writing this editorial, I was asked to perform emergency intervention on a patient transferred to our hospital in cardiogenic shock who had undergone several prolonged episodes of cardiopulmonary resuscitation. His neurological status was uncertain, but because of young age, unstable hemodynamics, and the wishes of a very involved family, I took the patient to the catheterization laboratory. With intra-aortic balloon pump placement and opening of his left anterior descending coronary artery, the patient stabilized, but combination of shock to his lungs and kidneys and poor cardiac function ultimately led to the patient’s death two weeks later. A colleague’s primary comment subsequently was admiration, not for clinical skill in stabilizing the patient, but for courage in accepting a likely increase in my personal 30-day mortality statistics. This scenario is surely not what the late Dr. David Axelrod had in mind when he pursued the institution of public reporting so vigorously.Would any of us want access to emergency intervention for our own family members curtailed because of fear of public reporting?

13. Public Reporting and Case Selection for Percutaneous Coronary Interventions: An Analysis From Two Large Multicenter Percutaneous Coronary Intervention DatabasesMauro Moscucci, Kim A. Eagle, David Share, Dean Smith, Anthony C. De Franco, Michael O’Donnell, Eva Kline-Rogers, Sandeep M. Jani, David L. BrownJournal of the American College of Cardiology, Volume 45, Issue 11, 7 June 2005, Pages 1759-1765

14. When to call for help?

15. Cumulative funnel plots for the early detection of interoperator variation: retrospective database analysis of observed versus predicted results of percutaneous coronary interventionBabu Kunadian, research fellow, Joel Dunning, specialist registrar in cardiothoracic surgery, Anthony P Roberts, clinical effectiveness specialist adviser, Robert Morley, clinical audit lead, Darragh Twomey, clinical teaching fellow, James A Hall, consultant cardiologist, Andrew G C Sutton, consultant cardiologist, Robert A Wright, consultant cardiologist, Douglas F Muir, consultant cardiologist, Mark A de Belder, consultant cardiologisBMJ 2008;336:931-934(26ﾊApril)