By Lisa Rapaport
(Reuters Health) – Public reporting of outcomes for a common procedure to clear blocked arteries was supposed to improve quality, but some doctors say it hasn’t delivered on the goal of enhancing patient care.
It’s been two decades since New York became the first state to require public reporting of outcomes from what’s known as an angioplasty, a procedure that uses a catheter to insert a tiny balloon and inflate it to open clogged arteries and also uses a stent, a tiny wire mesh cage, to keep vessels propped open. Since the requirement took effect, only a handful of states have followed suit, doctors note in JAMA Cardiology.
“It was quite reasonable to think that public reporting might improve quality by pointing out hospitals with suboptimal outcomes and either avoiding those hospitals or trying to raise their quality of care,” said senior author Dr. Deepak Bhatt, a researcher at Harvard Medical School and executive director of interventional cardiovascular programs at Brigham and Women’s Hospital in Boston.
“However, that is easier said than done,” Bhatt said by email.
Part of the problem, Bhatt and colleagues argue in an invited commentary, is that outcomes reporting has focused on mortality rates, which can be impacted by a lot of things that are beyond the control of doctors or hospitals, like how many chronic health problems patients have or their income and education levels.
“The risk of current public reporting is that it may provide a disincentive for hospitals to care for the sickest patients at highest risk of dying – in fact, there is already evidence of that,” Bhatt said.
Where outcomes are publicly reported, doctors have an incentive to treat only the healthier patients who are the least likely to have complications or require repeat hospitalizations for problems that crop up after they go home.
Roughly two-thirds of cardiologists in states with public outcomes reporting have turned away high-risk patients out of concern that it would negatively impact their statistics, according to results from a survey of 149 doctors in New York and Massachusetts that was published separately in JAMA Cardiology.
In addition, 59 percent of these specialists said they were sometimes or often pressured by colleagues to turn away high-risk patients because of concerns about the mortality risk.
“Public reporting tends to induce avoidance of procedures in the sickest patients, who may be at highest risk of adverse outcomes but may also derive the greatest benefits from these procedures,” said lead author of the survey paper, Dr. Daniel Blumenthal, a researcher at Massachusetts General Hospital and Harvard Medical School in Boston.
One thing public reporting doesn’t necessarily do is help patients make better decisions about which treatment to get or where to go for care, Blumenthal said by email.
Part of the problem may be that patients are not aware that outcomes data is out there for them to review or that they don’t know how to interpret the information to help make a decision, he added.
Patients also have other ways of choosing a cardiologist, said Dr. William Borden, co-author of an accompanying editorial and chief quality and population health officer at George Washington University Medical Faculty Associates in Washington, D.C.
“Choosing a physician for a cardiac stent is very different than choosing a restaurant for dinner,” Borden said by email.
“While someone might pick a restaurant by opening a rating app, someone picking an interventional cardiologist will likely already have a strong recommendation from their primary care provider or general cardiologist,” Borden added. “Even for patients who are aware of the public reporting websites, those ratings are one factor amongst many, including recommendations from their family, friends and doctors, a hospital’s general reputation, location and accessibility.”