Tag Archives: Patient Outcomes

Good Enough?

There are a few themes that permeate this blog – the impact of new technology on medical practice, evidence-based care, health care financing, and a patient-centered approach to care delivery. The recent dust-up over the release of surgeon-specific outcome data touches almost all of them.

ProPublica, a not-for-profit organization devoted to investigative “journalism in the public interest” got the ball rolling last week with the publication of their “surgeon scorecard.” They compiled 5 years of Medicare data (2009-2013) on 8 generally elective surgical procedures: Knee and hip replacement, laparoscopic cholecystectomy, lumbar spinal fusion (broken out by anterior and posterior approach), “complete” prostatectomy, TURP and cervical spinal fusion. For each one, they identified a list of principal diagnosis codes associated with a hospital re-admission within 30 days of the surgery that could reasonably be interpreted as complications of the index surgery. For example, if a patient had undergone knee replacement and was admitted within 30 days with a principal diagnosis of “infection due to prosthesis” then that “counted” as a complication of surgery. Details of the methodology were provided online. The complication rates were adjusted by patient age, gender, and a few other variables, and their user-friendly tool allows for easy look-up of complication rates by surgeon or hospital.

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Adjusting Outcomes

I wrote recently about the need to take into account patient characteristics when using patient outcomes to compare the quality of care provided by different physicians. That is a well-accepted principle, and the need for so-called “risk-adjustment” applies not only to evaluating physicians, but also to evaluating hospitals and larger care delivery systems. There has been a smoldering controversy, however, about which patient characteristics to consider and, in particular, the implications of including socioeconomic factors in such comparisons. This controversy played out again in a recent issue of the Annals of Internal Medicine.

Here is the core of the issue.

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Shared Accountability

There are plenty of good reasons why thoughtful physicians are often unhappy with the current approach to measuring the quality of care they provide. Some, of course, object to the whole notion of quality measurement, but I believe they are in a shrinking minority clinging to an anachronistic mental model in which each physician defines for himself what constitutes high quality care. I have addressed this previously. But even those, who like me, believe it is essential (and possible) to measure quality, can point to legitimate shortcomings in the way it is done.

Among these shortcomings is the imperfect process by which individual physicians’ “results” are “adjusted” to account for differences in the patients they care for. In the simplest case, when the quality of care is judged by looking at patient outcomes, this risk-adjustment is meant to reflect the fact that clinical outcomes reflect both the baseline characteristics of the patients being treated and the treatment they get. For example, if one were to use in-hospital mortality rates to assess the quality of care for acute myocardial infarction, it would be essential to know “how sick” the patients, on average, were on presentation. A 50 year-old man with a small inferior wall MI is likely to live even in the absence of good care (or any care for that matter), whereas a 90 year-old woman with cardiogenic shock from an anterior wall MI is likely to die even with state-of-the art care. Any attempt to assess the quality of care for a population of MI patients must take this into consideration.

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