The quality movement may well improve medical care. However, we must always consider the “unintended consequences” of any movement.
The influence of public reporting of outcome data on medical decision making by physicians.
The vast majority (79%) of interventional cardiologists agreed or strongly agreed that the publication of mortality statistics has, in certain instances, influenced their decision regarding whether to perform angioplasty on individual patients. Physicians expressed an increased reluctance to intervene in critically ill patients with high expected mortality rates. Among the respondents, 83% agreed or strongly agreed that patients who might benefit from angioplasty may not receive the procedure as a result of public reporting of physician-specific patients’ mortality rates. Additionally, 85% believed that the risk-adjustment model used in the Percutaneous Coronary Interventions (PCI) in New York State 1998-2000 report is not sufficient to avoid punishing physicians who perform higher-risk interventions.
This abstract (and article) should not surprise anyone. I have seen this phenomenon for at least 10 years. Surgeons worry about their mortality statistics and hence sometimes will not operate, when an operation is the only possible option.
Some high risk patients should have procedures and operations. Some patients understand that their only chance at improved quality of life is to take the chance on the procedure.
Certainly many obese patients take a mortality chance when choosing bariatric surgery. Most make that decision after full disclosure of risk.
The idea behind report cards seems sound, but what are the unintended consequences. Is the public health better, or do we have cardiologists “cherry picking” healthier patients and eschewing the more complex? Perhaps the report cards create a Catch-22 for some patients!
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