Heart Surgeons' Death Rates Published Online

Undergoing heart surgery? Now you may be able to check your surgeon's death rates before you reach the operating table.

Three states already offer patients an online peek at their heart surgeons' mortality data. Beginning Dec. 18, Massachusetts will become the fourth state to publish procedure-related death rates for individual heart surgeons.

In 1991, New York became the first state to report this data. Since then, New Jersey and Pennsylvania have followed suit. California and Florida are expected to make the information available next year.

With Massachusetts joining a growing number of states that make doctors' grades publicly available, experts say that there is a national trend towards publicizing doctors' performance records.

"An effective and accurate registry will greatly help patients and surgeons by helping us understand risks and outcomes," said Dr. John Byrne, chairman of the department of cardiac surgery at Vanderbilt University Medical Center in Nashville, Tenn.

But some experts debate the effectiveness of the system, even warning that it may cause surgeons to shy away from patients who are already severely ill.

"I think that surgeons will initially not take on high-risk cases," said Dr. Bruce Leavitt, professor of surgery at the University of Vermont and Fletcher Allen Health Care in Burlington, Vt.

"Even though the statisticians tell surgeons that taking on a high-risk patient will be compensated by the risk model, all of us know that when a high-risk patient dies, it affects our [record]."

Patients May Doctor-Shop for Heart Surgeons

Experts say patients may use this information to shop around for the best heart surgeons.

"It will tell [patients] where to go or not to go," said Dr. Lawrence Cohn, professor of cardiac surgery at Brigham and Women's Hospital in Boston.

"Some patients come to my office with lots of papers and information printed from the Internet," Leavitt said. "Technologically savvy patients and family will obtain information from the Internet."

But, he said, many patients may not have the opportunity to check the Internet when they are admitted to the hospital after a sudden event, such as a heart attack. In these cases, he said, "it is a bit difficult for them to get onto the Internet to check out a surgeon's statistics."

And checking a surgeon's background may work. A study that examined the New York heart surgeon report card system found that patients who picked a top-performing surgeon had half the chance of dying as did those who picked a surgeon from the bottom quartile.

However, researchers also found that the surgeons with the best records aren't getting more patients than those whose statistics are not as good. And doctors said the system may not yet offer the clearest picture to patients.

"Sometimes the slickest ad campaign gets the referral," said Dr. Abe Deanda, director of aortic surgery at Montefiore Medical Park in New York. "The public cannot be expected to make decisions based on poorly understood statistics, nor should they.

"There is too much room for misinterpreting results."

Doctors Debate Report Card Accuracy

Thirty-seven states and the District of Columbia have mandatory health care reporting systems for inaptient hospital data. Another 10 states have voluntary reporting systems.

A primary concern over setting up the report card system was ensuring that mortality data were adjusted to reflect riskier surgeries.

In short, heart surgeons who are willing to take on the sickest patients should not be penalized with lower scores.

"I feel pretty confident in the model, but it's not perfect," said Dr. Richard Shemin, president of the Massachusetts Society of Thoracic Surgeons and chairman of cardiothoracic surgery at Boston Medical Center.

While doctors grow accustomed to being graded during medical school, most are not excited at the prospect of being graded as professionals. Some heart surgeons are worried that their report cards -- even if adjusted to reflect riskier surgeries -- may not tell the whole story and will be misinterpreted by the public.

"[Open-heart bypass surgery] is now a small part of my practice," said Dr. Valluvan Jeevanandm, chief of cardiothoracic surgery at University of Chicago. "A surgeon like myself would look particularly poor because the denominator would be so small. They should publish data from all surgeries and completely risk-adjust."

Some experts say other factors must be considered before assigning a score to an individual surgeon.

"Other outcome measures, such as infection rates and other non-fatal complications, require precise definitions, and these will need to be determined," Byrne said.

Shemin said, "It's not always the skill set of the individual surgeon. It's the environment in which you work, the hospital resources, and ICUs, nurses, physician's assistants, and other complex services that come together."

Doctors May Avoid Sicker Patients to Get A's

"Doctors like to get A's," said Shemin. Having a report card system for heart surgeons raises the concern that some surgeons may avoid high-risk patients in order to get good grades.

Risk avoidance may even chase some surgeons out of practice. Researchers of the New York State report card system found that surgeons with the highest mortality data were much more likely than other surgeons to retire or leave practice after the release of each report card.

Surgeons' reluctance to take on risky patients may harm severely ill patients who might otherwise have a fighting chance.

"What will be missed [with the reporting] is the number of patients who die due to a decline in high-risk cases" because surgeons refuse to operate, said Jeevanandm.

A Trend Toward Greater Transparency

Some surgeons, however, said that reporting would not represent an extreme change in practice.

"I think in the end, surgeons are going to be business as usual," said Shemin. "They will go ahead and be concerned about their profile and their data, but that's human nature. And that is probably good."

And despite concerns over negative impact of report cards, publishing mortality data on heart surgeons appears to be gaining momentum. The report card system may soon be extended to include additional areas of medicine, such as other heart procedures.

"It is just a matter of time before individual mortality rates for more and more hospitals and individual surgeons will be available on the Internet," said Leavitt. "Having statistics on the Internet is appropriate, as long as there are explanations as to the statistical significance explained to the readers."

The report card "helps me to know how my faculty is performing in comparison to their peers at other hospitals, in the state and nationally," said Shemin. "There is no doubt that there is a desire for greater transparency in outcomes data. It is a good way to provide quality assurance, surgeon feedback, and hospital feedback."

How to access the doctors' report cards:

For New York State

For New Jersey

For Pennsylvania