Tuesday, January 11, 2005

Cherry Picking in New York State....
No, not a tourist attraction, but the rearing up of the ugly head of unintended consequences. From The New York Times:Cardiologists Say Rankings Sway Choices on Surgery:
An overwhelming majority of cardiologists in New York say that, in certain instances, they do not operate on patients who might benefit from heart surgery, because they are worried about hurting their rankings on physician scorecards issued by the state, according to a survey released yesterday.

The survey, which was sponsored by the School of Medicine and Dentistry at the University of Rochester, demonstrated the difficulty that many doctors have with the public disclosure of their performance data, an idea pioneered by New York State. In 1994, the state's Department of Health began to compile data on cardiologists performing coronary angioplasty, a less invasive procedure than bypass surgery for restoring blood flow to the heart.

Eighty-three percent of the cardiologists surveyed said that because the state reports the mortality rates of heart surgeons, patients who might benefit from angioplasty may not receive the procedure. In addition, 79 percent of the doctors said that the knowledge that mortality statistics would be made public had, at times, influenced their decision on whether to operate.
So eight out of ten believe that patients are denied potentially lifesaving procedures and almost as many admit that the scorecard had influenced their clinical decision making.
You think?
Many are leery of such "scorecards" because they don't believe that adequate allowances are made for the very sick patients who can affect the numbers. The difference in morbidity and mortality between an elective angioplasty and an emergent one is impressive:
Angioplasty, when performed as elective surgery, has a mortality rate of less than 1 percent. But when patients come to the hospital as they are suffering a heart attack, when their bodies are in shock and blood pressure is low, there is a 60 percent chance that they will die, Dr. Narins said. The chance of survival can be increased to 50 percent if surgery is performed.
If the numbers Dr. Narins quotes are correct, the physician is looking at a ten percent increase of survivability, but only up to the degree of a coin flip. "Why risk my scorecard and liability premium over a patient who is likely to die anyway?" Shocking? Uncaring? perhaps, but to 80 percent of New York cardiologists it is a reality.
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