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Hospital ratings complicate care of sickest

Mass. General rethinks when to do angioplasties

Christopher Bader, shown with his wife, Debra, was saved by aggressive treatment. Christopher Bader, shown with his wife, Debra, was saved by aggressive treatment. (Joanne Rathe/Globe Staff)
By Liz Kowalczyk
Globe Staff / April 1, 2009
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Public reporting of hospital death rates may be pushing Massachusetts cardiac specialists to treat some very sick heart patients less aggressively, sparking a debate among health officials and doctors over whether patients are being spared unnecessary and costly end-of-life treatment or denied procedures that might save their lives.

The disagreement has intensified since state health officials recently flagged Massachusetts General Hospital and Saint Vincent Hospital in Worcester for having higher-than-average death rates in heart patients receiving artery-opening stents, a procedure called angioplasty.

Cardiologists at Mass. General, who have prided themselves on placing stents in the sickest of the sick, said they have stopped performing such high-wire acts on some patients, particularly those with advanced cancer who could die within weeks. They acknowledged in a January letter to the state that they realized last year that they were doing angioplasty on "a relatively large number of patients with little hope of survival, and that we needed to modify our practices."

State health officials applaud this more conservative approach, saying that doing procedures on patients with scant hope of recovery wastes money and exposes them to unnecessary care and pain.

But cardiologists say decisions about who should undergo angioplasty are frequently not so clear cut. Often they have to be made quickly with incomplete information when patients arrive at the hospital in the midst of a heart attack. In such cases, doctors say, they fear that colleagues might decide against the procedure to avoid a potential bad outcome that would harm their hospital's reputation.

"Physicians are really struggling with this issue," said Dr. Frederic Resnic, director of cardiac catheterization at Brigham and Women's Hospital and lead author of a study suggesting that fewer high-risk patients are getting angioplasty since public reporting began in 2003. "There is a terrible conflict between the desire to do what's right for a specific patient who has a very slim chance of survival, and the impact on the [doctor] and their center if it doesn't work out."

Dr. Kenneth Rosenfield, an interventional cardiologist at Mass. General, said he's worried that a patient like Christopher Bader could be turned away if doctors become too skittish about taking on high-risk patients.

Bader, 54, and his wife, Debra, were walking their three dogs in the woods near their Medford home last July when he collapsed with his second heart attack in six months. Debra Bader started CPR, but because they were far from the road, he was without medical help for about 15 minutes.

Paramedics rushed Bader to Mass. General. Given how long Bader's brain had been without oxygen, Rosenfield estimated his chance of living at just 20 percent, even with angioplasty. With Bader still in cardiac arrest, Rosenfield didn't have time to consult with Bader's wife or a neurologist, and decided to do the procedure. Bader, he felt, deserved his best shot. "Do I withhold therapy because this guy could hurt my [mortality] numbers?" Rosenfield said.

Bader, a software engineer, survived without brain damage. "I feel great," he said recently.

Recent studies in Massachusetts and nationally suggest that cardiologists may be turning away more high-risk patients as an unintended consequence of public reporting, Resnic said. In a paper published in the Journal of the American College of Cardiology last month, Resnic and his coauthors reported that in 2005, the proportion of patients undergoing angioplasty in Massachusetts for cardiogenic shock - a life-threatening condition caused by poor heart function - dropped to 1.3 percent, from 2.3 percent in 2003, the year the state began publicly reporting angioplasty death rates. Since then, the rate has been level, he said.

In another study published last year, New York researchers found that in that state, which has the oldest public reporting system, patients having an acute heart attack and in shock were less likely to get angioplasty than in states without public reporting.

One problem, doctors contend, is that Massachusetts' methodology for determining whether mortality rates are excessive does not fully adjust for how seriously ill the patients at a particular hospital are, and thus how likely they are to die during angioplasty - even if the hospital provides excellent care.

Rosenfield said doctors were concerned that Department of Public Health officials were discussing possibly closing the hospital's angioplasty program earlier this year because of the high mortality rates in 2007, when smaller hospitals frequently transfer high-risk patients to Mass. General. Outside reviewers found no quality problems at either Mass. General or Saint Vincent, hospital executives said, and the state let both programs stay open.

Paul Dreyer, director of healthcare safety and quality for the department, said the studies about angioplasty rates in Massachusetts and New York are inconclusive. He said the state has one of the best methods in the country for adjusting mortality data for how sick patients are, already giving hospitals extra points for performing angioplasty on patients who are in shock. But as a result of the controversy, state officials are working with doctors to take into account more risk factors when calculating expected mortality rates. They also have postponed a decision to make public mortality rates for individual cardiologists, as the state does for heart surgeons.

"We certainly want [cardiologists'] cooperation, and we certainly don't have it," Dreyer said.

Rosenfield said doctors are more carefully scrutinizing every case, particularly advanced cancer patients - even though the doctors sometimes get pressure from the referring physician or family to do angioplasty.

Dr. Elliott Fisher, a professor at Dartmouth Medical School who studies overuse of medical care, said doctors must ask themselves if they are simply "prolonging the dying" by doing procedures on very sick patients. "If it's hopeless, you're subjecting patients who could be with their family in those moments to a procedure that has no benefits," he said.

But Dr. Harlan Krumholz, a cardiologist with Yale School of Medicine, said that even when it comes to cancer patients, the decisions aren't as easy as they first appear. Angioplasty on a patient with advanced cancer and severe chest pain can be considered palliative care.

"If that patient had metastatic cancer and a prognosis of six months, then I might do that patient," he said. "Their next six months are worth so much more to them than our next six months."

Liz Kowalczyk can be reached at kowalczyk@globe.com.

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