The Truth Is Out There. Sort Of.

Jay Moore, for HealthLeaders Media, January 29, 2009

This is a column about telling the truth, and it's a pretty tough one to write. Tough because when it comes to healthcare quality, the truth can be a complex, misleading, equivocal thing. So I've been putting off tackling such a touchy subject. But here goes.

A couple of weeks back I read a New York Times opinion piece about the question of whether physicians have an ethical obligation to tell patients that another hospital has better outcomes in treating certain kinds of cancer. The Times story referenced a lengthy article from the journal PLoS Medicine this past fall in which the authors contended that "full disclosure of outcomes research, whether it is during the mandated process of informed consent or the recommended shared decision-making part of care, is essential to maintain trust and honesty in the physician-patient relationship. More importantly, it will protect the cancer patient's autonomy and sense of control, a value of paramount importance for patient battling a potentially lethal disease."

Such an issue tends to spark a sort of mental involuntary reflex. Should physicians tell their patients that another facility offers better quality of care in treating a certain condition? Do we really have to ask that question? Of course they should. Lives are at stake. Failing to do so would be unethical and dishonest and not in the best interests of the patient. Debate over.

Except that the debate is more complicated than the simple matter of telling the truth about quality. I've read some analogies that attempt to discredit the notion of full disclosure—would a loan officer tell a borrower about the cheaper rates down the street, or would an airline notify potential passengers that competing Airline XYZ has had fewer problems noted in their safety inspections? Such arguments fall short, in my view, because healthcare is not aviation or lending or anything else. Healthcare is healthcare. If you're looking for an industry that's truly analogous, you won't find one.

What does give me pause, however, are the inherent complexities of measuring care quality that make the "truth" about which hospital is the "best" option an elusive concept. Case mix, for one. So Hospital A has better outcomes in treating a certain kind of cancer than Hospital B. But do Hospital A and B treat patients with the identical levels of risk? Somehow, I doubt it. And could a small community hospital's outcomes data become artificially inflated if all of the high-risk cases are transferred to the larger urban facility?

Individual circumstances, for another. The numbers might point to Hospital A, but are the specific physicians and nurses and technologies and countless other components of the care process really the best option on a certain day for a certain patient with a certain condition? And just because Hospital B's outcomes are inferior collectively, an individual surgeon at Hospital B might have above-average outcomes.

Data accuracy, for yet another. Many outcomes studies paint an accurate, insightful picture of care quality. And many outcomes studies paint an incomplete, perplexing picture of care quality. Even if one accepts the premise that certain information should be provided to a patient, the question of whether that information is accurate still remains.

It's worth mentioning that the authors of the PLoS Medicine article included contrary points of view that touched on some of these complicating factors—on the whole they did an admirable job addressing a delicate subject. And the ultimate message to be gleaned from this shouldn't be that outcomes disclosure must be categorically avoided. Providers have a responsibility to disclose their quality data and to point patients in the right direction to research all of their options. Still, there's a difference between disclosing your own outcomes data and trying to interpret someone else's outcomes data. Helping patients receive the best care they can sometimes includes referring a patient somewhere else when your facility just doesn't have the expertise or technological capability to provide a certain treatment. But I don't see how it's reasonable to expect physicians to evaluate convoluted information from a competing hospital and then tell a patient to seek treatment there instead based simply on that data. The "truth" about quality, unfortunately, is never that easy.

Jay Moore is managing editor for HealthLeaders magazine. He can be reached at
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