Some states require health-care providers to report outcomes about certain heart procedures, and some states don’t. A recent study in Journal of the American Medical Association (JAMA) of nearly 100,000 Medicare patients in 10 states showed that doctors in mandatory reporting states perform the procedures less often than doctors in states with no reporting requirement. But, it’s interesting to note, these differences don’t seem to have affected patient survival rates.
For background information on heart attacks, see our newsletter.
As reported in the Los Angeles Times, the analysis reflects a national interest in greater transparency about how health-care providers compare. This month, for example, marks the beginning of the Centers for Medicare & Medicaid Services’ imposition of financial penalties on hospitals that fall short of standards for readmission rates (also known as "bounce backs," where the patient returns to the hospital in less than 30 days after being sent home).
Many heart attack patients arriving at the ER are in acute distress and not likely to survive, no matter the intervention. Determining if any intervention would be likely to save the patient or be a futile effort can be tricky.
The most common procedure to clear blocked arteries is angioplasty. It involves threading a catheter through the artery to inflate a tiny balloon at the blockage site; often, a stent is installed to keep the artery open.
The JAMA study reviewed nine years of Medicare data about patients 65 and older who had suffered acute heart attacks. Thirty-eight percent of patients in the three states that require public reporting received an artery-opening procedure; 43 percent in seven states without the requirement got one. For patients with full blockages, the numbers were 62 percent versus 68 percent.
Thirty days after the patients presented, the overall death rates for both groups were about 12 in 100. Among patients with full blockages, the death rate in reporting states was 13.5 percent versus 11 percent in nonreporting states — a slight but statistically significant difference.
Many health policy professionals favor making performance data public to enable patients to make informed decisions about where they get care and to promote accountability among providers. If sunshine doesn’t always improve outcomes, some observers say it can backfire.
One cardiologist not involved in the study suggested that some extremely sick patients were being denied care because doctors were under pressure to keep their success rates high. Losing a patient would make them look bad, even if survival was doubtful from the get-go. If you’re forced to report outcomes, he said, some doctors just don’t do the procedures in hopeless cases.
The results of transplant surgery have long been made public in order to ensure that scarce organs aren’t wasted (see our recent blog post, “Why Organs Are Wasted, Not Transplanted.” ) And Medicare’s Hospital Compare site publishes information about hospital performance.
But many doctors are opposed to public reporting, and point to studies such as JAMA’s as justification. If sunshine doesn’t always cultivate improvement, does that mean performance should remain cloudy? Many health professionals, according to The Times, believe these studies and their results reinforce the need for improved performance measures that examine the differences among patients and promote valid comparisons. And, one hopes, offer ideas about how to refine care so people get what they need and resources are used wisely.
Another cardiologist who helped develop the outcome measures used by Medicare said the next steps were to determine why some providers did better than others, and then to spread the best practices throughout the healthcare system.
"Just putting the data online is not enough," he told The Times.
