Thursday, May 10, 2007

Unintended Consequences of Publicly Reporting Quality Information

is the title of a post at Healthcare Economist that quotes a review of health care report cards for a procedure called coronary artery bypass graft as follows:

"In Pennsylvania, which also introduced CABG report cards, 63% of cardiac surgeons admit to being reluctant to operate on high-risk patients, and 59% of cardiologists report having increased difficulty in finding a surgeon for high-risk patients with coronary artery disease since the release of report cards. New York had a similar experience after the release of report cards, reporting that 67% of cardiac surgeons refused to treat at least 1 patient in the preceding year who was perceived to be high risk."

I see this as a positive consequence of measuring the outcomes of medical procedures. Clearly, the surgeons don't want to put themselves in a position where they could potentially be sued. However, if the patient is defined to be high-risk, that means that regardless of who performs the surgery the patient is seen as having a high likelihood of dying on the operating table. A high risk patient faces two options: do nothing and hope that they live as long as possible, or undergo surgery where the probability of dying during surgery is high. I don't know what the average life expectancy for the patient if they choose not to have surgery is, but that would be important information to have before making the decision.

The key here is that if the surgeon doesn't think you'll survive surgery, you shouldn't have the operation. Not having the operation saves the patient and his/her insurance company and by extension every person in the country the cost of the surgery.

If the two states decided to eliminate the report cards, the result would be a return to high-risk patients undergoing surgery without real consideration of the risk of death, because there would be no incentive for surgeons to tell their patients that they think that surgery is too risky. In fact, surgeons would have financial incentive to disregard the relative risk for specific patients.

Remarkably, with respect to the procedure discussed here,

"The past 20 years has seen a proliferation of bypass surgery and angioplasty, in spite of strong scientific evidence that neither may be helpful in the long run for the overwhelming majority of patients. In general, the only reason for the one million such procedures each year is the high number of working cardiologists and cardiovascular surgeons in the medical community and the extremely high profitability of these procedures, around $70,000 for a bypass and $30,000 for an angioplasty.

The landmark CASS Study (stands for Coronary Artery Surgery Study) in 1984 demonstrated the irrelevance of bypass surgery and angioplasty to survival after the diagnosis of coronary artery disease is made. Analysis of outcome in 780 patients demonstrated no statistical difference in survivability between patients who both went to surgery and were treated medically and patients who were treated medically without surgery. Nevertheless, this extremely well documented study is generally ignored by doctors who do these procedures and never mentioned to patients who they consider candidates for bypass or angioplasty"...per Ron Kennedy, M.D., Santa Rosa, CA

In essence, surgeons are wasting money and killing patients...for profit...

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