Cardiology in Crisis

Cardiology in Crisis

Scoring doctors' cardiology success seemed like a good idea, until truly sick patients began being turned away.

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“When Doctors Slam the Door” by Sandeep
Jauhar, M.D., in
The New York Times
Magazine
(Mar. 16, 2003), 229 W. 43rd St.,
New York, N.Y. 10036.


It must have seemed an obviously good thing to do more
than a decade ago when the federal Health Care Financing
Admin­istration and several states began monitoring the performance of
heart surgeons and other medical professionals. In the early 1990s, New
York and Pennsylvania began publishing “report cards” for
public consumption. The idea behind all these efforts, notes Jauhar, a New
York City cardiology fellow, was “to improve the quality of
cardiac surgery by pointing out deficiencies in hospitals and
surgeons,” channeling patients toward the good ones and forcing the
deficient others to heal themselves. The worst surgeons might lose their
hospital operating privileges.


At first, there seemed to be amazing improvements. In
New York State, for example, “mortality rates for coronary bypass
surgery declined a whopping 41 percent.” (Nationwide, surgeons
perform some 500,000 bypasses annually.) But skeptics feared that surgeons
intent on boosting their scores might be declining to treat their sickest
patients. “In a survey a few years ago,” Jauhar reports,
“63 percent of cardiac surgeons in New York State said that because
of report cards, they were accepting only relatively healthy patients for
coronary bypass surgery.” Now there’s hard evidence, too.
Researchers at Northwestern and Stanford Universities who compared
1990–93 data from New York and Pennsylvania with data from states
with no such report cards found something striking: Patient health-care
expenditures over the year
before class="text28"> coronary bypass surgery dropped by seven percent in
the two states while staying about the same elsewhere. That’s
evidence that healthier patients were being “cherry picked” for
surgery. The decline in expenditures in New York and Pennsylvania
“was matched by a drop in the number of operations for sicker
patients. They experienced ‘dramatically worsened health
outcomes’ as a result, including more congestive heart failure and
recurrent heart attacks,” notes Juahar.


He sees “a kind of spiritual crisis in the field
of cardiac surgery. Heart surgeons, among the most highly trained and
fearless of specialists, are shrinking from taking on the toughest cases
because of statistics.”


The pity of it is that they’re the wrong
statistics. Some 98,000 Americans die every year because of medical errors,
but seldom is an individual surgeon—or nurse, or technician, or
anesthesiologist—solely responsible. “Health care is too
complex; outcomes depend on many variables,” Juahar believes. To
ensure real accountability, we must focus not on individuals but on the
systems that deliver our health care.