Potential Unintended Consequences of Public Reporting

The public reporting of cardiac surgery outcomes can benefit patients by providing meaningful information for making decisions regarding surgery. In addition, public reporting creates an environment that facilitates improvement in the quality of health care and challenges all hospitals and surgical practices to improve their results and outcomes. However, there can be potential unintended consequences of public reporting that may create other challenges. Public reporting can contribute to a more competitive business atmosphere, increasing the perceived importance of reporting “good” outcomes. Naturally, all surgeons and hospitals want their publicly reported outcomes to be as good as possible. One way to have “good” outcomes is to operate on only “good”—or low-risk—patients, who almost always do well after surgery.

The practice of avoiding high-risk patients has been termed risk aversion. The problem with such a strategy is that many of the sickest patients have the most to gain from surgery, despite their higher risk. Even with sophisticated risk-adjustment, providers may fear, justifiably or not, that the risk of some of their most severely ill patients might be underestimated.  In this situation, surgeons would be less willing to operate on such patients, fearing that their performance reports would be unfavorably impacted.  To address these concerns, STS has continually updated its Database to better reflect the risk of even the most critically ill and challenging patients.

In addition, although CABG and AVR are among the most commonly performed and the most studied heart operations on a national scale, timely comparison of individual results can be very difficult when a participant has a small number of cases and outcomes to analyze. Comparison of annual results can sometimes be misleading, despite the best efforts of statisticians to minimize this type of error. To illustrate, let’s look at the problem car insurance companies face in estimating risk among drivers. Let’s say you had an accident last year. If you were applying for insurance this year and the insurance company looked only at results from last year, you would probably be labeled as high risk and have difficulty getting insurance. If the insurance company looked back 10 years and you had only the one accident, you would probably be labeled as low risk and allowed to pay a lower rate. Death after heart surgery is a relatively rare event, thus making annual evaluations of mortality results challenging.  Fortunately, statistical techniques are utilized that adjust for small sample sizes, thus providing more stable and accurate assessments of performance.

It is hoped that STS Public Reporting Online can be of assistance to those facing coronary artery bypass grafting or aortic valve replacement surgery. However, selection of a surgeon and a hospital for heart surgery should consider a number of factors, not only these publicly reported measures. The reputation of the surgeon and the hospital, your personal interaction with the surgeon, the recommendation of your referring physician(s), and geographical location are all important considerations.