Cardiac surgeons have report cards: Are we next?
Joseph S Savino, M.D.
Report cards are designed to grade the performance of individuals (or teams). The “grades” on report
cards are used to determine whether the individual or team has achieved a certain performance level.
Report cards (whether in high school or in medicine) are intended to be improvement tools that define
which specific subject a person achieves at a high level or achieves at a not so high level. Improvements
in performance in specific areas can be targeted. Report cards are also used to compare the
performances between individuals or teams, creating the opportunity to rank providers based on
performance outcomes.
Traditionally, physician reimbursement has been based on the volume of care rendered. The more
cases you did, the more revenue you generated for yourself, your group, and your hospital. Volume
based care, although still the primary paradigm for payment in the United States, is expected to change
to value based care. The new initiative will be more regulated and is intended to reward for
performance and value based on patient outcomes and cost containment. The payment from payors
and CMS to a physician and hospital would be more closely linked to the “value” of care rendered as
defined by quality/cost. Quality is measured by a variety of metrics. Ideally quality of health care would
be measured by the improvement in the health of patients. Unfortunately, “health” is somewhat
difficult to nail down but not impossible. Measures of health outcome or corresponding surrogates
include risk adjusted mortality, myocardial infarction, stroke, time to return to work, patient
satisfaction, length of stay in a hospital, discharge to home versus a rehabilitation facility, and avoidance
of complications (e.g., sternal wound infection, reoperation, bleeding, dental injury, postoperative
cognitive dysfunction). Cardiovascular Anesthesiologists contribute in many of the areas where metrics
are attained by their work in perioperative care including work done in the cardiovascular intensive care
unit. Articulating and naming the end-points of care is not difficult. Defining reliable numeric metrics of
these endpoints is challenging. For example: what is the definition of a new myocardial infarction? Is it
a troponin leak greater than X after myocardial surgery or is it new Q waves? Is shortening length of
stay a worthwhile endpoint if it is related to increased 30 day re-admission rates? The cost of providing
care is a likely metric to be tracked. For example, an anesthesiologist who utilizes a pharmacy cost that
is a multiple of his/her colleagues with no difference in outcome would be deemed a provider of lesser
value.
Quality is often measured by adherence or deviation from agreed upon “best practices”. Conformity of
practices and decreasing unexplained variation in practices among physicians are gaining momentum in
our discipline. Timing of antibiotics, extubation times in the postop ICU, blood transfusion triggers,
intraop monitoring, DVT prophylaxis, aspirin, and beta-blockers (SCIP measures) are examples of tracks
of care where standardization has occurred and protocols written. Deviation from such protocols
without an identifiable reason is often considered “lesser” care. Early evidence suggests value based
care promotes health moreso than promoting the financial gains of the providers.
Report cards would have little utility if access to their contents were not open. But who shall have
access to physician report cards? The answer has been quite clear: nearly everyone; including patients,
payors, government, legal system, health systems and competing groups.
Report cards for cardiac surgery and cardiac surgeons began in 1989 in New York State.
Limitations of report cards are significant, lessons learned
1
2
Data is often from administrative or billing databases and not databases designed to capture
quality/ health/value. Administrative databases are the default databases used in report
cards (especially those from state governments) because they already exist. Creating new
quality and outcome health care databases (as the STS has done) is expensive and the
bearer of the cost is not defined.
Report cards change the behavior of physicians and teams and patients. When New York
State undertook the CT Surgery reporting system, the following changes occurred:
a
high risk patients were denied surgery because surgeons were more sensitive to
their mortality data
b
risk scores were upcoded.
c
patients had to leave NY and they sought their cardiac surgery in other states
The STS now publishes (via Consumer Report) report cards on cardiac surgery programs. One such
report is the STS CABG Composite Score of individual hospital performance. The Score is a one, two or
three star rating based on “Measures of Quality” in CABG patients. The metrics that are included in the
score include postop renal failure, reexploration, postop antiplatelet - beta-blocker - statin, death, preop
beta-blocker, intubation time, wound infection, stroke, use of IMA. Consumer Report provides scores in
other cardiac surgery outcome, process and structure measures of hospitals. Of importance is the
recent collaboration between the SCA and the STS to develop an STS Anesthesia Module. Soon
afterwards, it is anticipated that scores from the STS will include data from the Anesthesia fields. This is
an opportunity! The expectation is (should be) that anesthesiologists and those invested in our
practices will develop a better understanding of how the practices of Cardiovascular Anesthesiologists
affect patient health, outcome and cost of care. If managed in a goal-directed fashion, the SCA – STS
collaboration will offer an opportunity to, in part, measure the value for our clinical services.
Despite the recent developments, the future of cardiovascular anesthesia report cards remains ill
defined. The report cards for CV anesthesiologists may not come to fruition. In my opinion, some form
of “grading” will occur. The grading system may come from any of the following sources of data or a
combination: internal hospital or Department databases, local government (e.g., Pennsylvania Health
Care Cost Containment Counsel), Center Medicare Medicaid Services, and specialty societies (STS
Anesthesia module). Plausible metrics for cv anesthesiologists tracked in the future may include
protocol compliance, QA outliers, Focused Professional Practice Evaluation, Ongoing Professional
Practice Evaluation, room turnovers, start times, patient satisfaction scores, TEE performance and
certification, postop CTICU care, blood transfusion rates, and risk mitigation. There will be no paucity of
data. In fact, the system will be inundated with data and teasing out what is relevant will be a challenge.
Health care is moving toward a more service line approach. Health Systems are developing
cardiovascular service lines where the CV Anesthesiologists, Cardiac Surgeons, Cardiologists, Vascular
Surgeons, CV Imaging, etc have adjacent offices and collaborate on clinical and academic programs more
so with each other than with members of their own departments. Administratively, these service lines
have struggled when dealing with allocation of resources and distribution of revenue and incentives
across divisions and departments. Leadership and involvement (Dean/CEO) at the highest level of an
institution is necessary. Outcomes, such as the ones outlined above, are the product of a combination
of factors that are affected by a large number of health care providers. It makes sense that report cards
should reflect the performance of the team rather than the performance of an individual. Regardless of
system adopted, the development of such measured and reported metrics would, like it did for our Card
Surgeon counterparts, change the behavior and make up of our practice.
Hospital Data
Cartoon Hospital
CABG without Valve
● Rate significantly
Valve without CABG
higher than expected
Valve with CABG
Total Valve
○ Rate significantly lower
Ouchies Hospital
than expected
CABG without Valve
Valve without CABG
⌂ Rate not significantly
different than expected
Valve with CABG
Total Valve
Hospital of the Healthy
NR Not reported. Too
few cases
CABG without Valve
Valve without CABG
Valve with CABG
Total Valve
Allbetternow Hospital
CABG without Valve
Valve without CABG
Valve with CABG
Total Valve
LaTanya's Hospital
CABG without Valve
Valve without CABG
Valve with CABG
Total Valve
Cases
In-Hospital
Mortality
223
98
38
359
●
○
⌂
⌂
⌂
⌂
⌂
⌂
160
95
95
350
⌂
⌂
⌂
⌂
⌂
⌂
180
75
42
297
⌂
⌂
⌂
⌂
155
124
88
367
⌂
⌂
⌂
⌂
⌂
⌂
⌂
$77,283
$122,110
$119,674
$116,626
213
145
48
406
⌂
⌂
⌂
⌂
⌂
⌂
⌂
$218,130
$224,056
$255,259
$225,115
●
30-Day Readmission
NR
●
⌂
●
NR
●
●
Average Hospital Charge
$243,110
$268,229
$360,955
$299,346
$137,901
$199,262
$229,613
$206,549
$209,926
$209,923
$267,658
$226,747
Surgeon Data
● Rate significantly higher than
expected
○ Rate significantly lower than
expected
⌂ Rate not significantly
different than expected
NR Not reported. Too few cases
Dr Make Me Well
CABG without Valve
Valve without CABG
Valve with CABG
Total Valve
Dr Frank N. Stein
CABG without Valve
Valve without CABG
Valve with CABG
Total Valve
Dr Brain E. Act
CABG without Valve
Valve without CABG
Valve with CABG
Total Valve
Dr Money Maker
CABG without Valve
Valve without CABG
Valve with CABG
Total Valve
Dr. Do-Little
CABG without Valve
Valve without CABG
Valve with CABG
Total Valve
Cases
In-Hospital Mortality
30-Day Readmission
325
110
46
481
⌂
⌂
⌂
⌂
⌂
30
140
42
212
NR
NR
⌂
⌂
⌂
⌂
⌂
126
58
43
227
⌂
⌂
⌂
⌂
167
23
91
281
●
NR
⌂
⌂
NR
NR
●
179
82
64
325
⌂
⌂
⌂
⌂
⌂
⌂
⌂
⌂
○
●
⌂
●
⌂
○
⌂
○
⌂
1.
Are public report cards that evaluate individual physicians a good thing? Proto Massachusetts
General Hospital. Protomag.com. pp. 1-3.
2.
Berenson RA, Kaye DR: Grading a Physician’s Value – The Misapplication of Performance
Measurement. The New England Journal of Medicine. 2013; 369(22). pp. 2079-2081.
3.
Birkmeyer, JD, Finks JF, O’Reilly A, et al. Surgical Skills and Complication Rates after Bariatric
Surgery. The New England Journal of Medicine. 2013; 369. pp. 1434-1442.
4.
Cardiac Surgery in Pennsylvania: Information About Hospitals And Cardiothoracic Surgeons.
Pennsylvania Health Care Cost Containment Council. 2013. pp. 1-49.
5.
Chassin M: Improving The Quality of Health Care: What’s Taking So Long? Health Affairs. 2013;
32(10). pp. 1761-1765.
6.
Ferris TG, Torchiana DF: Public Release of Clinical Data – Online CABG Report Cards. The New
England Journal of Medicine. 2010; 363(17). pp. 1593-1595.
7.
Fleisher LA, Trey B: Turning Mission-Based Academic-Department Leaders into a Leadership
Team: A Case Study in Creating Value. The New England Journal of Medicine.
8.
Glance LG, Fleisher LA: Anesthesiologist and the Transformation of the Healthcare System: A
Call to Action. Anesthesiology. 2013; 120(2). pp. 1-3.
9.
Hannan EL, Cozzens K, King SB, et al. History, Contributions, Limitations, and Lessons for Future
Efforts to Assess and Publicly Report Healthcare Outcomes. Journal of the American College of
Cardiology. 2012; 59(25).
10.
Hawn MT, Graham LA, Richman JS, et al. Risk of Major Adverse Cardiac Events Following
Noncardiac Surgery in Patients With Coronary Stents. The Journal of the American Medical
Association. 2013; 310(14). pp. 1462-1472
11.
Jacobs DO: Cut Well, Sew Well, Do Well? The New England Journal of Medicine. 2013; 369. pp.
1466-1467.
12.
Looking For A Heart Surgeon? ConsumerReports.org. August 2011.
13.
Porter ME, Lee TH: The Strategy That Will Fix Health Care. Harvard Business Review. 2013.
14.
Stecker EC, Schroeder SA: Adding Value to Relative-Value Units. The New England Journal of
Medicine. 2013; 369(23). pp. 2176-2179.
15.
Todd MM, Fleisher LA: Avoiding Professional Extinction. Anesthesiology. 2013; 120(1). pp. 1-2.