Public reporting of surgical mortality: a survey of New York State cardiothoracic surgeons

Publicly reported provider outcomes: The concerns of cardiac surgeons in a single-payer system

“…High-risk case avoidance was also evident from the results of a survey in New York, USA (17). In the survey, New York cardiac surgeons were more likely to turn down high-risk coronary surgeries than aortic dissection procedures of similar risk for which there was no public outcomes report.…”

“…In the survey, New York cardiac surgeons were more likely to turn down high-risk coronary surgeries than aortic dissection procedures of similar risk for which there was no public outcomes report. In New York state, it was found that high-risk case avoidance was more prevalent in less experienced surgeons (17,18). In spite of public reporting of mortality rates for coronary surgery in the state of New York, high-performing hospitals and surgeons have not increased their market share of referrals and, in fact, even a few high-performing surgeons admitted to leaving the state due to "lack of enjoyment" in devising plans to ensure their reported mortality rates remained low (19).…”

“…Of 109 surgeons in New York (69% response rate), more than 37% of cardiac surgeons perceived that, as a result of public reporting, a significant proportion of their colleagues had changed the patient profile that they deemed operable, changed their practice from cardiac to predominantly thoracic surgery, and relocated to another state or retired. The survey also demonstrated that surgeons were not aware of comorbidity definitions, as demonstrated by a significant proportion choosing the wrong definition for chronic obstructive pulmonary disease (49%) (17). New York surgeons indicated that 'gaming' on the report card required improvement (40%) (17).…”

“…The survey also demonstrated that surgeons were not aware of comorbidity definitions, as demonstrated by a significant proportion choosing the wrong definition for chronic obstructive pulmonary disease (49%) (17). New York surgeons indicated that 'gaming' on the report card required improvement (40%) (17). This concern regarding 'gaming' in New York did not just exist in the collection of comorbidity data but also in the alteration of clinical practice including upgrading of procedures (eg, inserting a preoperative intra-aortic balloon pump or performing an additional procedure such as a ventricular aneurysm repair by applying a few sutures) and/or the expeditious transfer of moribund patients to other care facilities before death (17).…”

“…This concern regarding 'gaming' in New York did not just exist in the collection of comorbidity data but also in the alteration of clinical practice including upgrading of procedures (eg, inserting a preoperative intra-aortic balloon pump or performing an additional procedure such as a ventricular aneurysm repair by applying a few sutures) and/or the expeditious transfer of moribund patients to other care facilities before death (17). In response to this, the New York state cardiac surgery advisory board began to audit procedures to help capture and correct such manipulations (17). In Ontario, we have observed some differences in comorbidity coding at the hospital level, which chart audit has demonstrated to reflect misinterpretation of comorbidity definitions.…”