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

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

• Paul Barach, MD, MPH
• UMC U

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• May 29, 2006

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Variation in death rates and charges in US
hospitals
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Variation in CABG rates per 1000 Medicare
Enrollees
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• May 1, 2006

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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. 2005142756-764.
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A single death is a tragedy, a million deaths
is a statistic Joseph Stalins comment to
Winston Churchill at the Potsdam Conference, 1944

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Mr. Altmans 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 states Health
Department. While the death rate is quite
lowfewer than 4 of all bypass operationsit 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.
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The influence of public reporting of outcome
data on medical decision making by
physiciansC.R. Narins, A.M. Dozier and F.S. Ling
Arch Intern Med 2005165837.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.
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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.
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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 patients death two weeks later. A
colleagues 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?
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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 ODonnell, 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
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When to call for help?
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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
cardiologis BMJ 2008336931-934(26?April)
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