Stop the Blustering About High-risk Patients

Cheryl Clark, October 21, 2010

Public disclosure about surgeons' open-heart outcomes has been controversial ever since New York released the nation's first state mortality scorecard for coronary artery bypass graft surgery (CABG) in 1991.

Providers in New York and elsewhere have complained that it's impossible to adjust such reports to fairly reflect factors that put their patients at higher risk of dying. To score surgeons like that, some say, provokes hospitals and doctors to cherrypick their cases, refusing patients they think might be more likely to die within 30 days.

Indeed, cardiac surgeons in New York and Pennsylvania, states where mortality of patients undergoing CABG is regularly reported, have answered surveys saying they were subsequently less likely to accept higher risk patients, according to a report earlier this year by Patrick Romano MD, Clinical Lead for the Agency for Healthcare Research and Quality's national Quality Indicators program.  Similar reporting is done in three other states, California, New Jersey and Massachusetts.

If this is true, it would mean some patients would be left to die without care, or would have to travel out of state to get it.  I recall physicians insisting to me that they couldn't afford to have such patients pull their reputations down—though they felt bad about sending such patients away.

But Romano, professor of general medicine and pediatrics at the University of California at Davis, an expert on quality outcome reporting metrics, says there's little evidence in the data to back up their claims.

"Despite all of this concern about discrimination against high-risk patients, empirical evidence of this phenomenon is very limited," he says.
In other words, patients are not being turned away in droves.  And surgeons who claim that they are being turned away may be full of bluster.  Maybe they just don't like the transparency.


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