Wednesday, July 11, 2007

Surgeon rankings have unintended consequences, doctors say

Dr. Thomas H. Lee knows the headline he wrote is provocative: "Is Zero the Ideal Death Rate?"

But the network president of Partners Health Care and associate editor at the New England Journal of Medicine is concerned that public reporting of mortality rates for individual cardiac surgeons carries unintended, perverse consequences. He fears that surgeons might hesitate to operate on high-risk patients if they are seeking a perfect performance record, he and two colleagues write in tomorrow's issue of the journal.

"If you are being ranked, you may walk away from a patient who’s very sick, even though that patient may be at high risk for surgery but even higher risk with medicine" as treatment, he said in an interview. "When so few patients can swing things for you being ranked, we’re worried about that effect on the decision-making process."

Lee, along with co-authors Dr. David F. Torchiana, a cardiac surgeon at Massachusetts General Hospital, and Dr. James E. Lock, an interventional cardiologist at Children’s Hospital Boston, say that reporting on cardiac surgery by institution makes sense, with individual reports available only to those hospitals. Massachusetts recently joined New York, New Jersey and Pennsylvania in publicly reporting death rates for individual cardiac surgeons.

Two elements make individual reports undesirable, they said. The first problem is that risk-adjustment methods intended to account for how sick a patient is do not include variables such as socioeconomic status. The second problem is the small sample size. If the average death rate after coronary artery bypass surgery is 2 percent, one or two deaths among the 200 operations a surgeon performs can make a large difference in that surgeon’s ranking, the authors say.

Lee said a better way to report performance would be the measures the federal government chose when it rated hospitals recently: better than expected, as expected, and worse than expected.

"I worry about having a patient with diabetes who’s doing very poorly. They may have a 20 percent mortality rate with surgery but an 80 percent mortality rate without surgery," he said. "I don’t want to have to beg surgeons to operate."

Posted by Elizabeth Cooney at 05:41 PM

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