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 It's been two decades since New York became the first state to
require public reporting of outcomes from what's known as an
angioplasty, a procedure that uses a catheter to insert a tiny
balloon and inflate it to open clogged arteries and also uses a
stent, a tiny wire mesh cage, to keep vessels propped open. Since
the requirement took effect, only a handful of states have followed
suit, doctors note in JAMA Cardiology.
"It was quite reasonable to think that public reporting might
improve quality by pointing out hospitals with suboptimal outcomes
and either avoiding those hospitals or trying to raise their quality
of care," said senior author Dr. Deepak Bhatt, a researcher at
Harvard Medical School and executive director of interventional
cardiovascular programs at Brigham and Women's Hospital in Boston.
"However, that is easier said than done," Bhatt said by email.
Part of the problem, Bhatt and colleagues argue in an invited
commentary, is that outcomes reporting has focused on mortality
rates, which can be impacted by a lot of things that are beyond the
control of doctors or hospitals, like how many chronic health
problems patients have or their income and education levels.
"The risk of current public reporting is that it may provide a
disincentive for hospitals to care for the sickest patients at
highest risk of dying - in fact, there is already evidence of that,"
Bhatt said.
Where outcomes are publicly reported, doctors have an incentive to
treat only the healthier patients who are the least likely to have
complications or require repeat hospitalizations for problems that
crop up after they go home.
Roughly two-thirds of cardiologists in states with public outcomes
reporting have turned away high-risk patients out of concern that it
would negatively impact their statistics, according to results from
a survey of 149 doctors in New York and Massachusetts that was
published separately in JAMA Cardiology.
In addition, 59 percent of these specialists said they were
sometimes or often pressured by colleagues to turn away high-risk
patients because of concerns about the mortality risk.
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"Public reporting tends to induce avoidance of procedures in the
sickest patients, who may be at highest risk of adverse outcomes but
may also derive the greatest benefits from these procedures," said
lead author of the survey paper, Dr. Daniel Blumenthal, a researcher
at Massachusetts General Hospital and Harvard Medical School in
Boston.
One thing public reporting doesn't necessarily do is help patients
make better decisions about which treatment to get or where to go
for care, Blumenthal said by email.
Part of the problem may be that patients are not aware that outcomes
data is out there for them to review or that they don't know how to
interpret the information to help make a decision, he added.
Patients also have other ways of choosing a cardiologist, said Dr.
William Borden, co-author of an accompanying editorial and chief
quality and population health officer at George Washington
University Medical Faculty Associates in Washington, D.C.
"Choosing a physician for a cardiac stent is very different than
choosing a restaurant for dinner," Borden said by email.
"While someone might pick a restaurant by opening a rating app,
someone picking an interventional cardiologist will likely already
have a strong recommendation from their primary care provider or
general cardiologist," Borden added. "Even for patients who are
aware of the public reporting websites, those ratings are one factor
amongst many, including recommendations from their family, friends
and doctors, a hospital's general reputation, location and
accessibility."
SOURCE: https://bit.ly/2Iu5iic , https://bit.ly/2IqXP74 and https://bit.ly/2InVSZD
JAMA Cardiology, online May 9, 2018.
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