Risk Aversion and Public Reporting. Part 1: Observations From Cardiac Surgery and Interventional Cardiology
2017; Elsevier BV; Volume: 104; Issue: 6 Linguagem: Inglês
10.1016/j.athoracsur.2017.06.077
ISSN1552-6259
AutoresDavid M. Shahian, Jeffrey P. Jacobs, Vinay Badhwar, Richard S. D’Agostino, Joseph E. Bavaria, Richard L. Prager,
Tópico(s)Patient Safety and Medication Errors
ResumoRisk aversion is a potential unintended consequence of health care public reporting. In Part 1 of this review, four possible consequences of this phenomenon are discussed, including the denial of interventions to some high-risk patients, stifling of innovation, appropriate avoidance of futile interventions, and better matching of high-risk patients to more capable providers. We also summarize relevant observational clinical reports and survey results from cardiovascular medicine and surgery, the two specialties from which almost all risk aversion observations have been derived. Although these demonstrate that risk aversion does occur, the empirical data are much more consistent and compelling for interventional cardiology than for cardiac surgery. Risk aversion is a potential unintended consequence of health care public reporting. In Part 1 of this review, four possible consequences of this phenomenon are discussed, including the denial of interventions to some high-risk patients, stifling of innovation, appropriate avoidance of futile interventions, and better matching of high-risk patients to more capable providers. We also summarize relevant observational clinical reports and survey results from cardiovascular medicine and surgery, the two specialties from which almost all risk aversion observations have been derived. Although these demonstrate that risk aversion does occur, the empirical data are much more consistent and compelling for interventional cardiology than for cardiac surgery. For extreme diseases, extreme methods of cure … are most suitable—Hippocrates, Aphorisms, circa 400 BCDesperate diseases grown, By desperate appliance are relieved, Or not at all—Shakespeare, Hamlet, Act 4 Scene 3, circa 1600 AD For some severe diseases and conditions, the only hope for cure may be treatments that have a high-risk of failure, complications, or death. Although we may think of this as a phenomenon of 21st century health care, these familiar quotes from Hippocrates and Shakespeare illustrate the perennial nature of this challenging problem. The concept that some clinicians might not offer treatment to such patients because of the high risk of failure and its potential effect on their reputations—referred to today as risk aversion—is also not a modern phenomenon. More than a century ago, Ernest Amory Codman, a surgeon at the Massachusetts General Hospital and Harvard Medical School, was one of the earliest advocates for transparent reporting of provider outcomes. Dr Codman was subsequently a cofounder of both the American College of Surgeons and its Committee on Hospital Standardization, a forerunner of the Joint Commission, and he is now widely recognized as the father of the American health care quality movement. Although an ardent advocate for transparency, Codman also presciently reflected on its potential unintended consequences. In 1913 he presented what is probably the earliest, and still one of the most insightful commentaries regarding risk aversion [1Codman E.A. The product of a hospital.Surg Gynecol Obstet. 1914; 18: 491-496Google Scholar]:But if we think too much about mortality, shall we not fail to do desperate operations which we should do?Who should attempt these desperate operations—the man anxious to make a reputation, or the man who has made one?The operation of gastrectomy for cancer of the stomach is a good example. A mortality even as high as 50 per cent is justifiable, because unfavorable as well as favorable cases should be done. But what surgeon doing private practice has reputation enough to undertake such a mortality? To be successful with this operation a man should have great surgical skill, special training on animals, abundant opportunities to do the operation, and security of reputation, so that his private practice will not be ruined by the necessarily high mortality.Which of us with cancer of the stomach would not be willing to take a 50 per cent chance in skilled hands? Like Hippocrates and Shakespeare, Codman notes that serious illnesses sometimes require “desperate” cures, especially when the alternative is almost certain death. But he also observes that not everyone should undertake such risky procedures. Rather, it should be the most experienced and skilled clinicians, with special training and established reputations. He anticipated the value of matching high-risk patients to the most capable surgeons, a potentially positive consequence of risk aversion that will be discussed in the next section. In the current era of transparency and public reporting of health care outcomes [2Shahian D.M. Edwards F.H. Jacobs J.P. et al.Public reporting of cardiac surgery performance: part 1—history, rationale, consequences.Ann Thorac Surg. 2011; 92: S2-S11Abstract Full Text Full Text PDF PubMed Google Scholar, 3Shahian D.M. Edwards F.H. Jacobs J.P. et al.Public reporting of cardiac surgery performance: part 2—implementation.Ann Thorac Surg. 2011; 92: S12-S23Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar], with few standards to ensure the adequacy and accuracy of performance measures [4Shahian D.M. Normand S.L. Friedberg M.W. Hutter M.M. Pronovost P.J. Rating the raters: the inconsistent quality of health care performance measurement.Ann Surg. 2016; 264: 36-38Crossref PubMed Scopus (20) Google Scholar, 5Shahian D.M. Mort E.A. Pronovost P.J. The quality measurement crisis: an urgent need for methodological standards and transparency.Jt Comm J Qual Patient Saf. 2016; 42: 435-438Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar], the issue of risk aversion has never been more relevant or timely [6Rosenbaum L. Scoring no goal—further adventures in transparency.N Engl J Med. 2015; 373: 1385-1388Crossref PubMed Scopus (21) Google Scholar, 7Hannan E.L. The public reporting risk of performing high-risk procedures: perception or reality?.JACC Cardiovasc Interv. 2015; 8: 17-19Crossref PubMed Scopus (9) Google Scholar, 8Kirtane A.J. Nallamothu B.K. Moses J.W. The complicated calculus of publicly reporting mortality after percutaneous coronary intervention.JAMA Cardiol. 2016; 1: 637-638Crossref PubMed Scopus (3) Google Scholar, 9Gupta A. Yeh R.W. Tamis-Holland J.E. et al.Implications of public reporting of risk-adjusted mortality following percutaneous coronary intervention: misperceptions and potential consequences for high-risk patients including nonsurgical patients.JACC Cardiovasc Interv. 2016; 9: 2077-2085Crossref PubMed Scopus (19) Google Scholar, 10Young M.N. Yeh R.W. Public reporting and coronary revascularization: risk and benefit.Coron Artery Dis. 2014; 25: 619-626Crossref PubMed Scopus (4) Google Scholar, 11Wasfy J.H. Borden W.B. Secemsky E.A. McCabe J.M. Yeh R.W. Public reporting in cardiovascular medicine: accountability, unintended consequences, and promise for improvement.Circulation. 2015; 131: 1518-1527Crossref PubMed Scopus (47) Google Scholar, 12Turi Z.G. The big chill: the deleterious effects of public reporting on access to health care for the sickest patients.J Am Coll Cardiol. 2005; 45: 1766-1768Crossref PubMed Scopus (22) Google Scholar, 13Resnic F.S. Welt F.G. The public health hazards of risk avoidance associated with public reporting of risk-adjusted outcomes in coronary intervention.J Am Coll Cardiol. 2009; 53: 825-830Crossref PubMed Scopus (116) Google Scholar, 14Werner R.M. Asch D.A. The unintended consequences of publicly reporting quality information.JAMA. 2005; 293: 1239-1244Crossref PubMed Scopus (466) Google Scholar, 15Westaby S. Publishing individual surgeons’ death rates prompts risk averse behaviour.BMJ. 2014; 349: g5026Crossref PubMed Scopus (27) Google Scholar, 16Pepper J.R. Coonar A.S. High-risk surgery: the courage to fail.J R Soc Med. 2015; 108: 44-46Crossref PubMed Scopus (10) Google Scholar]. In Part 1 of this two-part review, we describe several potential consequences of risk aversion, some of which, paradoxically, might actually be beneficial to patients. We also review observational and survey studies regarding risk aversion in cardiac surgery and interventional cardiology. Part 2 of this review [17Shahian D.M. Jacobs J.P. Badhwar V. D’Agostino R.S. Bavaria J.E. Prager R.L. Risk aversion and public reporting. Part 2: mitigation strategies.Ann Thorac Surg. 2017; 104: 2102-2110Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar] explores the root cause of risk aversion—lack of provider trust in the risk-adjusted outcomes measures used for public reporting—and a variety of mitigation strategies are discussed. Risk aversion usually refers to the denial of interventions to high-risk patients who might have benefited, specifically when that decision is motivated by fear that worse outcomes among such patients will affect a provider’s reputation, referrals, privileges, or reimbursement. This adverse response to public reporting must be carefully monitored and mitigated for the value of transparency to outweigh its unintended consequences. For the overall population of patients with a particular disease to have optimal outcomes, it is necessary that some very high-risk patients receive interventions, and some will likely not survive [18Jones R.H. In search of the optimal surgical mortality.Circulation. 1989; 79: I132-I136PubMed Google Scholar, 19Lee T.H. Torchiana D.F. Lock J.E. Is zero the ideal death rate?.N Engl J Med. 2007; 357: 111-113Crossref PubMed Scopus (24) Google Scholar]. Similar to denial of care to high-risk patients, a related concern is that risk aversion suppresses medical and surgical innovation [20Cohoon K.P. Mack M.J. Holmes D.R. Public reporting: a new threat to high-risk patients and medical innovation.Catheter Cardiovasc Interv. 2017; 89: 335-337Crossref PubMed Scopus (1) Google Scholar, 21Bavaria J. Presidential address: quality and innovation in cardiothoracic surgery: colliding imperatives? Presented at the 53rd Annual Meeting of The Society of Thoracic Surgeons, Houston, Texas, January 21–25, 2017.Google Scholar]. Promising new techniques and treatments with substantial potential benefit may initially have a somewhat elevated risk. In a public reporting environment, practitioners may be unwilling to accept this risk even if fully informed patients are willing to do so. Although risk aversion is usually regarded as undesirable provider behavior, heightened risk awareness by providers may sometimes have salutary effects. For example, realistic appreciation of insurmountable risk in some cases, combined with thoughtful shared decision making, might spare some patients and their families the ordeal of a hopeless intervention. However, accurate risk estimation and incorporation of the patient’s and family’s goals of care may prove challenging even in very high-risk cases [22Hawkins B.M. Fitzgerald-McKeon L.M. Yeh R.W. High-risk percutaneous coronary intervention in the era of public reporting: clinical and ethical considerations in the care of an elderly patient with critical left main disease and shock.Circulation. 2014; 129: 258-265Crossref PubMed Scopus (5) Google Scholar]. Another potential benefit of risk aversion in a public reporting environment is improved matching of the highest-risk patients to the highest-performing providers (e.g., lower mortality rates or observed-to-expected [O/E] ratios) [23Hannan E.L. Kilburn Jr., H. Racz M. Shields E. Chassin M.R. Improving the outcomes of coronary artery bypass surgery in New York state.JAMA. 1994; 271: 761-766Crossref PubMed Scopus (666) Google Scholar, 24Chassin M.R. Hannan E.L. DeBuono B.A. Benefits and hazards of reporting medical outcomes publicly.N Engl J Med. 1996; 334: 394-398Crossref PubMed Scopus (308) Google Scholar, 25Hannan E.L. Cozzens K. King 3rd, S.B. Walford G. Shah N.R. The New York state cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes.J Am Coll Cardiol. 2012; 59: 2309-2316Crossref PubMed Scopus (126) Google Scholar, 26Dranove D. Kessler D. McClellan M. Satterthwaite M. Is more information better? The effects of “report cards” on health care providers.J Polit Econ. 2003; 111: 555-588Crossref Scopus (398) Google Scholar, 27Romano P.S. Marcin J.P. Dai J.J. et al.Impact of public reporting of coronary artery bypass graft surgery performance data on market share, mortality, and patient selection.Med Care. 2011; 49: 1118-1125Crossref PubMed Scopus (32) Google Scholar, 28Glance L.G. Dick A. Mukamel D.B. Li Y. Osler T.M. Are high-quality cardiac surgeons less likely to operate on high-risk patients compared to low-quality surgeons? Evidence from New York state.Health Serv Res. 2008; 43: 300-312Crossref PubMed Scopus (19) Google Scholar, 29Burack J.H. Impellizzeri P. Homel P. Cunningham Jr., J.N. Public reporting of surgical mortality: a survey of New York state cardiothoracic surgeons.Ann Thorac Surg. 1999; 68: 1195-1200Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar]. For example, recognizing their own limitations, surgeons who are less capable or experienced might decline a very high-risk patient; however, the patient may subsequently be referred to a better-qualified surgeon, thus resulting in a better match of patient and provider. Over time, referral patterns adapt, and high-risk patients are preferentially referred to higher-performing providers. Glance and colleagues [28Glance L.G. Dick A. Mukamel D.B. Li Y. Osler T.M. Are high-quality cardiac surgeons less likely to operate on high-risk patients compared to low-quality surgeons? Evidence from New York state.Health Serv Res. 2008; 43: 300-312Crossref PubMed Scopus (19) Google Scholar] studied coronary artery bypass grafting (CABG) procedures between 1997 and 1999 in the New York Cardiac Surgery Reporting System. Patients at higher risk were more likely to be operated on by surgeons with better outcomes. For each 10% absolute increase in the estimated risk of patient death, there was an absolute decrease of 0.034 in surgeon O/E ratios (p < 0.001). Much of this effect seemed to be driven by the hospital where the surgeon practiced, but even within hospitals, the higher-risk patients were more often cared for by higher-quality surgeons. Virtually all modern studies of risk aversion and public reporting come from the disciplines of cardiac surgery and interventional cardiology. These fields have the requisite combination of high-acuity patients, risky but potentially life-saving treatments, readily measurable outcomes with standardized definitions, and relatively large volumes. Lessons learned in the domain of cardiovascular care should be readily transferrable to other areas of health care as public reporting becomes more pervasive. The modern era of public reporting began with the short-lived but seminal publication of hospital mortality rates by the Healthcare Financing Administration (the predecessor of the Centers for Medicare and Medicaid Services) from 1986 to 1993, including mortality rates for CABG. Hospitals complained that the reputations of their cardiac surgery programs were being unfairly impugned because Healthcare Financing Administration analyses had inadequate risk adjustment [30Kouchoukos N.T. Ebert P.A. Grover F.L. Lindesmith G.G. Report of the ad hoc committee on risk factors for coronary artery bypass surgery.Ann Thorac Surg. 1988; 45: 348-349Abstract Full Text PDF PubMed Scopus (72) Google Scholar, 31Green J. Wintfeld N. Sharkey P. Passman L.J. The importance of severity of illness in assessing hospital mortality.JAMA. 1990; 263: 241-246Crossref PubMed Scopus (188) Google Scholar, 32Blumberg M.S. Comments on HCFA hospital death rate statistical outliers. Health Care Financing Administration.Health Serv Res. 1987; 21: 715-739PubMed Google Scholar]. This led The Society of Thoracic Surgeons (STS) to advocate for the use of robustly risk-adjusted outcomes based on clinical registry data. This was the proximate stimulus for the development of the STS National Database and numerous risk models and performance measures based on these data. In 2010 the STS initiated a voluntary public reporting program that, as of mid 2017, has the enrollment of approximately 60% of participants in the STS Adult Cardiac Surgery Database and 67% of participants in the STS Congenital Heart Surgery Database [2Shahian D.M. Edwards F.H. Jacobs J.P. et al.Public reporting of cardiac surgery performance: part 1—history, rationale, consequences.Ann Thorac Surg. 2011; 92: S2-S11Abstract Full Text Full Text PDF PubMed Google Scholar, 3Shahian D.M. Edwards F.H. Jacobs J.P. et al.Public reporting of cardiac surgery performance: part 2—implementation.Ann Thorac Surg. 2011; 92: S12-S23Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 33Shahian D.M. Grover F.L. Prager R.L. et al.The Society of Thoracic Surgeons voluntary public reporting initiative: the first 4 years.Ann Surg. 2015; 262: 526-535Crossref PubMed Scopus (53) Google Scholar]. During roughly the same time frame, cardiac surgery public reporting efforts were also initiated in several states [25Hannan E.L. Cozzens K. King 3rd, S.B. Walford G. Shah N.R. The New York state cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes.J Am Coll Cardiol. 2012; 59: 2309-2316Crossref PubMed Scopus (126) Google Scholar, 34Harlan B.J. Statewide reporting of coronary artery surgery results: a view from California.J Thorac Cardiovasc Surg. 2001; 121: 409-417Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 35Massachusetts Data Analysis Center reports. Available at http://www.massdac.org/reports/cardiac-study-annual/. Accessed June 5, 2017.Google Scholar]. New York State Health Commissioner David Axelrod was concerned about high unadjusted CABG mortality rates at some New York hospitals. Recognizing the inadequacy of raw outcomes data, health policy leaders, including Professor Ed Hannan and Dr Mark Chassin, developed a clinical registry, the Cardiac Surgery Reporting System (CSRS), together with risk models and risk-adjusted performance measures to more accurately assess CABG providers in New York State [23Hannan E.L. Kilburn Jr., H. Racz M. Shields E. Chassin M.R. Improving the outcomes of coronary artery bypass surgery in New York state.JAMA. 1994; 271: 761-766Crossref PubMed Scopus (666) Google Scholar, 24Chassin M.R. Hannan E.L. DeBuono B.A. Benefits and hazards of reporting medical outcomes publicly.N Engl J Med. 1996; 334: 394-398Crossref PubMed Scopus (308) Google Scholar, 25Hannan E.L. Cozzens K. King 3rd, S.B. Walford G. Shah N.R. The New York state cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes.J Am Coll Cardiol. 2012; 59: 2309-2316Crossref PubMed Scopus (126) Google Scholar, 36Hannan E.L. Kumar D. Racz M. Siu A.L. Chassin M.R. New York state’s cardiac surgery reporting system: four years later.Ann Thorac Surg. 1994; 58: 1852-1857Abstract Full Text PDF PubMed Scopus (172) Google Scholar, 37Hannan E.L. Kilburn Jr., H. O’Donnell J.F. Lukacik G. Shields E.P. Adult open heart surgery in New York state. An analysis of risk factors and hospital mortality rates.JAMA. 1990; 264: 2768-2774Crossref PubMed Scopus (482) Google Scholar, 38Chassin M.R. Achieving and sustaining improved quality: lessons from New York state and cardiac surgery.Health Affairs. 2002; 21: 40-51Crossref PubMed Scopus (218) Google Scholar]. Provider results were first made public at the hospital level in 1990, followed by the release of surgeon-level data in 1991. At about the same time, the Pennsylvania Health Care Cost Containment Council also embarked on a CABG public reporting initiative [34Harlan B.J. Statewide reporting of coronary artery surgery results: a view from California.J Thorac Cardiovasc Surg. 2001; 121: 409-417Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar], as did New Jersey, and Massachusetts followed in 2003 [35Massachusetts Data Analysis Center reports. Available at http://www.massdac.org/reports/cardiac-study-annual/. Accessed June 5, 2017.Google Scholar]. Soon after these CABG public reporting initiatives were implemented, investigators began to study their effects [2Shahian D.M. Edwards F.H. Jacobs J.P. et al.Public reporting of cardiac surgery performance: part 1—history, rationale, consequences.Ann Thorac Surg. 2011; 92: S2-S11Abstract Full Text Full Text PDF PubMed Google Scholar, 3Shahian D.M. Edwards F.H. Jacobs J.P. et al.Public reporting of cardiac surgery performance: part 2—implementation.Ann Thorac Surg. 2011; 92: S12-S23Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar]. Topics included reductions in risk-adjusted mortality rates [23Hannan E.L. Kilburn Jr., H. Racz M. Shields E. Chassin M.R. Improving the outcomes of coronary artery bypass surgery in New York state.JAMA. 1994; 271: 761-766Crossref PubMed Scopus (666) Google Scholar, 36Hannan E.L. Kumar D. Racz M. Siu A.L. Chassin M.R. New York state’s cardiac surgery reporting system: four years later.Ann Thorac Surg. 1994; 58: 1852-1857Abstract Full Text PDF PubMed Scopus (172) Google Scholar, 39Hannan E.L. Siu A.L. Kumar D. Kilburn Jr., H. Chassin M.R. The decline in coronary artery bypass graft surgery mortality in New York state. The role of surgeon volume.JAMA. 1995; 273: 209-213Crossref PubMed Scopus (316) Google Scholar], the surprising lack of effect of high or low outlier designation on market share [38Chassin M.R. Achieving and sustaining improved quality: lessons from New York state and cardiac surgery.Health Affairs. 2002; 21: 40-51Crossref PubMed Scopus (218) Google Scholar, 40Jha A.K. Epstein A.M. The predictive accuracy of the New York state coronary artery bypass surgery report-card system.Health Aff (Millwood). 2006; 25: 844-855Crossref PubMed Scopus (100) Google Scholar], the subjective impressions of providers [29Burack J.H. Impellizzeri P. Homel P. Cunningham Jr., J.N. Public reporting of surgical mortality: a survey of New York state cardiothoracic surgeons.Ann Thorac Surg. 1999; 68: 1195-1200Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar, 41Hannan E.L. Stone C.C. Biddle T.L. DeBuono B.A. Public release of cardiac surgery outcomes data in New York: what do New York state cardiologists think of it?.Am Heart J. 1997; 134: 55-61Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 42Schneider E.C. Epstein A.M. Influence of cardiac-surgery performance reports on referral practices and access to care—a survey of cardiovascular specialists.N Engl J Med. 1996; 335: 251-256Crossref PubMed Scopus (363) Google Scholar] and patients [43Schneider E.C. Epstein A.M. Use of public performance reports: a survey of patients undergoing cardiac surgery.JAMA. 1998; 279: 1638-1642Crossref PubMed Scopus (321) Google Scholar], gaming of the reporting system [44Green J. Wintfeld N. Report cards on cardiac surgeons—assessing New York state’s approach.N Engl J Med. 1995; 332: 1229-1233Crossref PubMed Scopus (313) Google Scholar], and the specific subject of this review, risk aversion. Omoigui and colleagues [45Omoigui N.A. Miller D.P. Brown K.J. et al.Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes.Circulation. 1996; 93: 27-33Crossref PubMed Scopus (198) Google Scholar] studied 482 New York CABG patients referred to Cleveland Clinic between 1989 and 1993, which they regard as the time period that referral patterns might have been affected by New York public reporting. In the prereport card era (1980 to 1988), 61.4 patients per year transferred from New York to Cleveland Clinic, which increased to 96.2 patients per year between 1989 and 1993, when referrals from other states were decreasing. New York referral patients had a higher prevalence of high-risk characteristics compared with those from other referral areas and with their own historical data. During the study period, New York patients had the highest expected mortality rates of any referral areas to Cleveland Clinic, and they had correspondingly higher morbidity and mortality. However, the authors acknowledged that the expected mortality rates of New York referrals rose only slightly between 1989 and 1993, given that the 4-year model may have underestimated the 1989 expected mortality rates; during the same time period, observed and adjusted mortality rates of New York CABG referrals steadily declined. The methods and conclusions of this frequently cited study have been challenged. Chassin and colleagues [24Chassin M.R. Hannan E.L. DeBuono B.A. Benefits and hazards of reporting medical outcomes publicly.N Engl J Med. 1996; 334: 394-398Crossref PubMed Scopus (308) Google Scholar, 38Chassin M.R. Achieving and sustaining improved quality: lessons from New York state and cardiac surgery.Health Affairs. 2002; 21: 40-51Crossref PubMed Scopus (218) Google Scholar] noted that the first New York report card was published in 1990 and the first plausible effect on risk avoidance would likely not have been until 1991, 2 years after the beginning of the post-report card study period as defined by Omoigui and colleagues [45Omoigui N.A. Miller D.P. Brown K.J. et al.Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes.Circulation. 1996; 93: 27-33Crossref PubMed Scopus (198) Google Scholar]. The 482 New York patients in their study [45Omoigui N.A. Miller D.P. Brown K.J. et al.Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes.Circulation. 1996; 93: 27-33Crossref PubMed Scopus (198) Google Scholar] represented a very small fraction (0.65%) of the 74,359 New York patients who had CABG from 1989 to 1993, most of which (73,877) were performed in New York. Also, there was very modest change in the expected mortality of New York referral patients from 1989 to 1990 (before public reporting) to 1991 to 1993 (after public reporting). In fact, between 1990 and 1992, the number of high-risk (>7.5% expected mortality) patients receiving CABG in New York increased from 804 to 1391 (73%) [24Chassin M.R. Hannan E.L. DeBuono B.A. Benefits and hazards of reporting medical outcomes publicly.N Engl J Med. 1996; 334: 394-398Crossref PubMed Scopus (308) Google Scholar]. Market share data showed no evidence of market shift from high-mortality to low-mortality hospitals [38Chassin M.R. Achieving and sustaining improved quality: lessons from New York state and cardiac surgery.Health Affairs. 2002; 21: 40-51Crossref PubMed Scopus (218) Google Scholar, 40Jha A.K. Epstein A.M. The predictive accuracy of the New York state coronary artery bypass surgery report-card system.Health Aff (Millwood). 2006; 25: 844-855Crossref PubMed Scopus (100) Google Scholar], which argues against referral pressure on surgeons to avoid high-risk patients. Finally, Chassin and colleagues [24Chassin M.R. Hannan E.L. DeBuono B.A. Benefits and hazards of reporting medical outcomes publicly.N Engl J Med. 1996; 334: 394-398Crossref PubMed Scopus (308) Google Scholar] noted that New York referrals to Cleveland Clinic were largely based on longstanding and often geographically based referral patterns. Dranove and colleagues [26Dranove D. Kessler D. McClellan M. Satterthwaite M. Is more information better? The effects of “report cards” on health care providers.J Polit Econ. 2003; 111: 555-588Crossref Scopus (398) Google Scholar] studied Medicare acute myocardial infarction (AMI) and CABG patients during the period 1987 to 1994, which includes the introduction of CABG public reporting in New York and Pennsylvania. Several investigators [24Chassin M.R. Hannan E.L. DeBuono B.A. Benefits and hazards of reporting medical outcomes publicly.N Engl J Med. 1996; 334: 394-398Crossref PubMed Scopus (308) Google Scholar, 25Hannan E.L. Cozzens K. King 3rd, S.B. Walford G. Shah N.R. The New York state cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes.J Am Coll Cardiol. 2012; 59: 2309-2316Crossref PubMed Scopus (126) Google Scholar] have questioned this study’s methods, particularly the idiosyncratic approach (total inpatient hospital expenditures for the year before admission) used to characterize severity of illness. However, with this caveat, the study findings do provide potential insights into the effect of public reporting. After these report cards were published, a shift occurred in CABG demographics in New York and Pennsylvania toward healthier patients (3.7% to 5.3% decrease in illness severity relative to all other states), putatively as a result of risk aversion. In contrast to this overall pattern, CABG illness severity was maintained at New York and Pennsylvania teaching hospitals, which the authors used as a proxy for high-quality institutions. This suggests that teaching hospitals were being sent the sickest CABG patients, who might previously have been cared for at other institutions. The authors also found that the average severity of AMI patients in New York and Pennsylvania teaching hospitals increased markedly, but there was no change at nonteaching hospitals. Similar to the findings of Glance and colleagues [28Glance L.G. Dick A. Mukamel D.B. Li Y. Osler T.M. Are high-quality cardiac surgeons less likely to operate on high-risk patients compared to low-quality surgeons? Evidence from New York state.Health Serv Res. 2008; 43: 300-312Crossref PubMed Scopus (19) Google Scholar] and Romano and associates [27Romano P.S. Marcin J.P. Dai J.J. et al.Impact of public reporting of coronary artery bypass graft surgery performance data on market share, mortality, and patient selection.Med Care. 2011; 49: 1118-1125Crossref PubMed Scopus (32) Google Scholar], these findings all suggest a potentially beneficial if unintend
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