Study: Public Disclosure Makes Docs More Cautious

Concern about record may bias physicians against surgery for sicker patients

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By
HealthDay Reporter

WEDNESDAY, June 8, 2005 (HealthDay News) -- Do heart doctors who have to publicly report the outcome of every procedure they perform cherry-pick the best patients for surgery, to keep their success rates high?

Maybe so, contends a study in the June 7 issue of the Journal of the American College of Cardiology.

The study found that patients undergoing angioplasty in New York state -- where angioplasty outcomes are entered into the public record by law -- were much less likely than patients in Michigan -- which has no public reporting requirements -- to have an underlying illness that might up their risk of dying during the procedure.

The study also found that the Michigan angioplasty patients' risk of dying was double that for the New York patients. However, when the data was adjusted to account for the sicker Michigan patients, that risk equalized, according to the study authors.

"Public reporting has its good and bad aspects," said one of the study's authors, Dr. Mauro Moscucci, director of interventional cardiology and the cardiac catheterization laboratory at the University of Michigan in Ann Arbor.

"It promotes accountability. And because physicians are concerned about their numbers being publicly available, they'll want to make them as good as possible. On the other hand, public reporting may have the unintended effect of denying patient care. Physicians may decline to treat cases with a potentially negative impact [on their record]," he added.

Moscucci and his colleagues believe that a possible explanation for the differences in the types of patients treated in New York and in Michigan is that New York doctors are choosing not to treat patients they believe won't do well.

A previous study, reported in the January 2005 issue of the Archives of Internal Medicine, seems to support Moscucci's assertion that New York doctors may be declining to treat the sickest patients because of the state's public reporting legislation.

In that study, almost 80 percent of interventional cardiologists -- doctors who perform angioplasty -- said public reporting had in some way influenced their decision to treat certain patients.

At least one New York expert disagreed with both studies' findings, however.

"I would challenge the idea that New York doctors are turning sicker patients away," said Dr. Samin Sharma, director of interventional cardiology at Mt. Sinai Medical Center in New York City.

"People in New York are more affluent. They're seeing their doctors, coming in early and getting screenings," he said. That means, he added, that their cardiac problems are detected and treated at an earlier stage.

Moscucci acknowledged there could be other reasons explaining differences between the New York and Michigan patients. One is that the two populations may be different, especially since the Michigan database had information from only eight Michigan hospitals. Another reason, he said, is that New York doctors may be better at selecting appropriate patients for the procedure.

Sharma agreed. "High volume equals better outcomes," he said. "High-volume hospitals and physicians have lower complication rates."

The current analysis compared more than 69,000 New York angioplasty patients from 34 hospitals to almost 11,400 Michigan patients from eight centers. Angioplasty is a procedure used to unblock coronary arteries. A thin catheter is placed into a blood vessel and threaded up to the heart where X-ray images detail the blockage, allowing doctors to clear it and open up the artery.

Michigan patients were much more likely to undergo angioplasty for a heart attack or cardiogenic shock, a condition where the heart isn't pumping enough blood to the rest of the body, than those in New York, the study found. Just over 14 percent of Michigan patients compared to 8.7 percent of New York patients were treated with angioplasty for a heart attack. For cardiogenic shock, those numbers were 2.6 percent and 0.4 percent respectively.

People in the Michigan group were also more likely to have congestive heart failure, other cardiac disease and chronic obstructive pulmonary disease.

Nevertheless, the New York patients were much more likely to survive their hospital stay and have slightly fewer complications after the procedure than Michigan patients. The in-hospital mortality rate was 0.83 percent for the New York group and 1.54 percent for the Michigan group.

But when the researchers adjusted the data to account for the sicker Michigan patients, these mortality rates are "not any different," Moscucci pointed out.

"In states where public reporting is ongoing, physicians may be reluctant to intervene [surgically] with high-risk patients, and may treat them medically instead," Moscucci said.

Sharma said he doesn't believe this is what's happening in New York and added that any differences in patient population were probably because the data come from two different states. "Once groups are different, it's hard to compare them," he said.

But he wasn't surprised that outcomes were better in New York.

"In any data which have been published for interventional cardiology, we traditionally have much lower complications compared to other databases," he said.

More information

To learn more about angioplasty, visit the National Library of Medicine.

SOURCES: Mauro Moscucci, M.D., associate professor, medicine, and director, interventional cardiology and cardiac catheterization laboratory, University of Michigan, Ann Arbor, Mich; Samin Sharma, M.D., director, interventional cardiology, Mt. Sinai Medical Center, New York City; June 7, 2005 Journal of the American College of Cardiology

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