Public Reporting Should Focus on Institutions or Teams, Not Individuals, CV Surgeons Say
Although public reporting of mortality data is meant to assure high-quality care and make patients feel confident at times when their health is vulnerable, the question of where the statistics should come from and what they should reflect continues to be a subject of contentious debate, as evidenced by a new survey of British surgeons.
While this particular survey focused on surgical outcomes reporting, the results speak to a broader debate taking place in cardiovascular disease care over the value of public reporting across disciplines.
“The survey suggests that the majority of cardiothoracic surgeons in the UK support outcome reporting but at an institutional or heart-team based level, rather than at the individual level,” said Omar A. Jarral, MRCS (Imperial College London, London, United Kingdom), in an email. “They also support the publication of more advanced measures of outcome in addition to mortality, such as a composite measure of care (ie, the star-rating system used by STS).”
In the July issue of Circulation: Cardiovascular Quality and Outcomes, Jarral and colleagues describe their survey of cardiothoracic surgeons’ opinions about the release of surgeon-specific mortality data, which they say the National Health Service began in 2013 without first getting feedback from major stakeholders.
Overwhelming Response Correlates With Concerns
Those who responded to the survey were varied in their subspecialization, years of experience, and geographic locations. Overall, the January 2015 survey captured responses from nearly 75% of the 361 cardiothoracic surgeons then practicing in the United Kingdom, with 52% of those making at least one comment in the box designated for feedback.
While some of the comments supported the concept of public reporting, others voiced frustration that they were not being listened to by policymakers and others. To TCTMD, Jarral said the comments “were particularly illuminating.” Some examples included:
“It ignores the contribution of the whole wider team who also impact significantly on mortality and other outcomes.”
“I know of many instances where high-risk patients have been denied surgery. The reasons given in the documentation are always other patient-related factors, but at the back of the surgeons’ mind is the feeling that mortality in these particular patients may impact on surgeon-specific mortality data.”
“Mortality is only one measure of outcome; it is an unsophisticated descriptor of patient experience as a whole, and cannot be used without also examining ‘softer’ measures of quality, as well as the experience of patients referred for but not undergoing surgery for whatever reason (capture turn-downs, waiting list deaths, etc) thus taking a true intention-to be-treated population, and not the I-chose-to-treat population.”
About 40% said surgeon-specific data are important in assessing the overall ability of a surgeon, and 38% said these data are important in assessing quality of care.
But the majority of those who took the survey (58.1%) said they strongly or somewhat oppose the public release of surgeon-specific mortality data, with greater years of experience clocking in as a strong predictor of opposition. Concerns about risk-averse behavior, misinterpretation of the data by both patients and referring clinicians/cardiologists, and the “gaming” of patient disease status and comorbidities during data collection were highly evident in the survey responses.
Jarral noted that one of the main messages from the surgeons seems to be that outcome reporting at an individual level does not reflect the multidisciplinary nature of care that patients receive.
“The results suggest policy makers should refine their strategy behind publication of surgeon-specific mortality data and possibly consider a shift towards team-based results for which there will be the required support,” he noted. “Stakeholder feedback and an inclusive strategy should be completed before introducing major initiatives to avoid unforeseen circumstances and disagreements.”
Burdens Parallel Those of PCI Reporting
In an opinion piece published earlier this year and endorsed by the American College of Cardiology Interventional Council and Board of Governors, Tanveer Rab, MD (Emory University, Atlanta, GA), and Hadley Wilson, MD (Carolinas Medical Center, Charlotte, NC), voiced concern about public reporting of PCI outcomes, noting in particular that including patients with out-of-hospital cardiac arrest or cardiogenic shock when tallying PCI mortality rates would lead to risk-averse behavior. Rather than continuing to expand public reporting of PCI mortality rates, Rab and Wilson recommended continuing to collect data on all PCI patients but excluding the two high-risk groups from risk-adjusted PCI mortality rates.
Commenting on the UK survey for TCTMD, Rab said it reflects many common themes between cardiac surgeons and interventional cardiologists regarding public reporting.
“Cardiac surgeons and interventional cardiologist are often faced with high-risk patients. Patient outcomes are multifactorial, however, and not [the result] of one person,” Rab said. “Hence, if quality and transparency is truly the intent, there should be support for reporting team-based outcomes or hospital-based outcomes.”
Additionally, Rab said, the very real concerns about gaming the system and risk aversion only serve to hurt, rather than help, patients and their physicians.
“It puts us in a situation where either we say we’re not going to take on high-risk people and just let them die, or we are going to salvage lives,” he observed. “That’s a terrible burden to have on your shoulder because of risk reporting.”
Implications for the United States
In an accompanying editorial, Erica S. Spatz, MD, MHS (Yale University School of Medicine, New Haven, CT), says that whether the findings for UK-based cardiothoracic surgeons “reflect the complaints of an overburdened physician group that has not fully embraced outcome measurement or [are] a signal of a health system that is ill prepared to use outcome measures” is critically relevant for the United States in light of the redesign of the Medicare Access and CHIP Reauthorization Act (MACRA). It is expected to include a merit-based incentive pay system, which will likely include clinician-specific outcome measures.
Implementation of MACRA, which is expected in 2019, provides the US with an opportunity to follow the UK’s lead in measuring physician-specific outcomes, Spatz notes. But defining what and why such measurements are being made is important to “foster a culture of data transparency and trust,” and “support physicians to achieve their personal best in the operating room and as part of the perioperative care team.”
- Jarral and Rab report no relevant conflicts of interest.
- Spatz reports receiving support from the Centers for Medicare and Medicaid Services to develop and maintain performance measures that are used in public reporting programs; she is currently developinga measure of informed consent document quality.
- Public Reporting of PCI Mortality: Debate Swirls Around What’s Fair, What’s Ethical
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- Public Reporting of PCI Mortality Tied to Fewer High-Risk Cases But Better Outcomes
Jarral OA, Baig K, Pettengell C, et al. National survey of UK consultant surgeons’ opinions on surgeon-specific mortality data in cardiothoracic surgery. Circ Cardiovasc Qual Outcomes. 2016;Epub ahead of print.
Spatz ES. Fostering a culture to support surgical outcome measures. Circ Cardiovasc Qual Outcomes. 2016;Epub ahead of print.