Correspondence
Cardiac-Surgery Performance Reports
N Engl J Med 1997; 336:442-443February 6, 1997
- Article
To the Editor:
In their examination of the influence of cardiac-surgery performance reports on referral practices and access to care, Schneider and Epstein (July 25 issue)1 note, “Now, employers, patients, and insurers are all pressing for more and better publicly released data on outcomes and other indicators of the quality of care to guide a comparative evaluation of physicians, hospitals, and health plans.” However, they studied only the effects of the Pennsylvania Consumer Guide to Coronary Artery Bypass Graft Surgery 2-5 on cardiovascular specialists and ignored the very groups that they say are demanding and using the “report cards” — employers, patients, and insurers.
Physician report cards are important in the era of managed care. Physicians are often added or dropped from provider panels on the basis of quantitative tracking of outcomes and costs associated with their performance. Large health care buyers are demanding a quantitative demonstration of quality and outcomes before purchasing the services of managed-care firms. However, the extent to which the use of report cards determines access to or denial of services, their overall effects on quality, and the weight patients assign them are not known.
5 ReferencesLloyd M. Krieger, M.D., M.B.A.
UCLA Medical Center, Los Angeles, CA 900491
Schneider EC ,Epstein AM . Influence of cardiac-surgery performance reports on referral practices and access to care -- a survey of cardiovascular specialists. N Engl J Med 1996;335:251-256
Full Text | Web of Science | Medline2
A consumer guide to coronary artery bypass graft surgery. Vol. I. 1990 Data. Harrisburg: Pennsylvania Health Care Cost Containment Council, 1992.
3
A consumer guide to coronary artery bypass graft surgery. Vol. II. 1991 Data. Harrisburg: Pennsylvania Health Care Cost Containment Council, 1994.
4
A consumer guide to coronary artery bypass graft surgery. Vol. III. 1992 Data. Harrisburg: Pennsylvania Health Care Cost Containment Council, 1994.
5
A consumer guide to coronary artery bypass graft surgery. Vol. IV. 1993 Data. Harrisburg: Pennsylvania Health Care Cost Containment Council, 1995.
To the Editor:
Contrary to Schneider and Epstein's opinion, a shift in cardiovascular-referral patterns is not the primary goal of the Pennsylvania Health Care Cost Containment Council. Our mission is improvement of the quality of health care and cost containment through public accountability. This may have the effect of changing physicians' patterns of referral over time, but the end result is not reliant on that. Providers with high mortality rates among their patients can also take steps to improve their results, as have several hospitals in Pennsylvania that perform cardiac surgery.
In fact, mortality rates associated with coronary bypass dropped 26 percent during the first four years in which results were publicly reported. The average increases in the costs of bypass surgery dropped from 10 percent in 1991 to 4.6 percent in 1993. Increases in overall hospital expenses rose a mere 1 percent in 1995, the smallest increase in six years.
Although the survey indicates that many cardiovascular specialists in Pennsylvania do not use the council's data, others clearly do. A survey of Pennsylvania consumers conducted by the General Accounting Office revealed that those who requested the Consumer Guide to Coronary Artery Bypass Graft Surgery found it informative and useful in their decision concerning where to seek medical care.1 The data are also used by hospitals, researchers, and group purchasers of health care.
According to the authors, cardiovascular specialists believe that access to open-heart surgery has decreased for severely ill patients. But evidence of an overall pattern of denied access has yet to surface. In fact, 2500 more bypass operations were performed by Pennsylvania surgeons in 1993 than in 1990, with no decrease in the number of patients with serious risk factors.
With respect to the involvement of physicians in the process, the council's Technical Advisory Group (which includes a cardiologist, a cardiac surgeon, and other physicians), the Hospital Association of Pennsylvania, the Pennsylvania Medical Society, and the Pennsylvania Osteopathic Medical Association have been closely involved in the development of these reports. The council's latest report, Focus on Heart Attack in Pennsylvania, 2 was developed in response to their recommendation.
Many cardiovascular specialists were very supportive of Focus on Heart Attack, so perhaps perspectives are changing. The council's efforts to improve the quality of care, reduce costs, and help the public make more informed health care decisions have benefited greatly from the cooperation and advice of the medical community.
2 ReferencesErnest J. Sessa
Pennsylvania Health Care Cost Containment Council, Harrisburg, PA 17101Author/Editor Response
The authors reply:
To the Editor: Many of the interventions aimed at changing physicians' practices for purposes of cost containment and quality improvement, of which performance reports are just one, are established at substantial cost without a rigorous evaluation of their effectiveness. We believe that such evaluations are critically important for policy decisions about quality monitoring in a market-driven health care system.
Our study assessed the attitudes of cardiovascular specialists because they are an essential component of the delivery of cardiac surgical services. We agree with Dr. Krieger about the importance of understanding how others, including hospitals, insurers, employers, and patients, use performance reports, especially since cardiovascular experts have expressed doubts about the interpretability of mortality data and concern about the adverse effects such reports may have on access to care.
The Pennsylvania Health Care Cost Containment Council has made a substantial effort to work collaboratively with the medical community. The program in Pennsylvania and a similar program in New York State are among the most thoughtfully and thoroughly implemented examples in what remains a primitive but rapidly developing field.
We agree with Mr. Sessa that there are many paths to quality improvement. Among the most powerful may be those that engage providers in improving their own practices.1 Physicians have in many instances been slow to recognize the need for quality improvement. Pioneering outcome-measurement efforts like those in Pennsylvania have had a galvanizing effect. It would be unfair to expect that these programs would not confront thorny problems or need evaluation or refinement. Like Mr. Sessa, we believe perspectives are changing. The more the role of performance reports is clarified, methods for risk adjustment are refined, and the best formats for dissemination and education are identified, the more likely it is that performance reports will serve the public without undercutting access for those who most need medical care.
1 ReferencesEric Schneider, M.D.
Arnold Epstein, M.D.
Harvard Medical School, Boston, MA 021151
Greco PJ ,Eisenberg JM . Changing physicians' practices. N Engl J Med 1993;329:1271-1274
Full Text | Web of Science | Medline
