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Monday, March 17, 2003The surgeon said that agencies monitoring surgical outcomes had been putting tremendous pressure on surgeons to produce good results. He was referring to ''report cards'' on cardiac surgeons. Over the past decade, while surgeons with higher-than-expected mortality statistics have lost operating privileges, others with lower-than-predicted rates have taken to advertising on the radio. Because the surgeon and his colleagues had been aggressive about treating very sick patients like P., they had incurred higher mortality rates and had been penalized by the state department of health. This was an insult he could no longer countenance, and so he had decided that all high-risk surgeries would be transferred to another hospital. And it isn’t just this one surgeon: In a survey a few years ago, 63 percent of cardiac surgeons in New York State said that because of report cards, they were accepting only relatively healthy patients for coronary-bypass surgery. Fifty-nine percent of cardiologists confirmed that it had become harder to find a surgeon to operate on their most severely ill patients. ''Hospitals getting cited are turning down high-risk patients,'' Dr. Eugene Grossi, a professor of surgery at N.Y.U. School of Medicine, recently told me. ''Some of the so-called best hospitals are only doing the most straightforward cases.'' ....Were surgeons' numbers improving because of better performance, or was it because patients like P. were not getting the operations they needed? Last January, researchers at Northwestern and Stanford tried to answer this question. Using Medicare data, they studied all elderly patients in the United States who had heart attacks or had coronary-bypass surgery in 1987 (before report cards were used) and 1994 (after they took effect). They compared New York and Pennsylvania, states with mandatory surgical report cards, with the rest of the country. What they discovered was that there was a significant amount of ''cherry picking'' in the states with mandatory report cards. For example, they found that between 1990 and 1993, patient health-care expenditures over the year before coronary-bypass surgery dropped by 7 percent in New York and Pennsylvania but stayed roughly the same in the rest of the country, suggesting that coronary-bypass operations started being performed on healthier patients. This was matched by a drop in the number of operations for sicker patients, who experienced ''dramatically worsened health outcomes'' as a result, including more congestive heart failure and recurrent heart attacks. The researchers concluded that surgical report cards in New York and Pennsylvania led to substantial selection bias by surgeons and that patients generally were worse off for it. This isn’t good. It’s never good to practice medicine by statistics, which is what “report cards” are. They shift the focus of the physician from the individual he’s treating, who has his own sets of risks and benefits to consider, and the likelihood of his individual outcome, to the overall statistical outcome of a population. It's like the high school student who obsesses about his grade average rather than what he's actually learning. posted by Sydney on 3/17/2003 08:49:00 AM 0 comments 0 Comments: |
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