Heart surgery data may go public

State looking at patient death rates for doctors

By Liz Kowalczyk, Globe Staff | July 4, 2006

State public health officials will decide this summer whether to publicize the patient death rates for individual physicians who perform two common heart procedures, giving Massachusetts patients unprecedented information about their doctors' performance.

Governor Mitt Romney has vowed to make the quality and cost of healthcare more transparent, but the mortality statistics, covering thousands of heart procedures performed annually, will test how far the governor is prepared to push openness. Health officials in New York, which has collected and released mortality data for individual cardiac doctors since 1991, said the program has lowered the mortality rate for patients.

But many Massachusetts cardiac surgeons and cardiologists strongly oppose making the mortality data available to consumers, saying this approach could actually hurt care by discouraging doctors from taking high-risk patients who are more likely to die. They are pressing health officials to keep private one of the most detailed and carefully analyzed physician data sets in the country.

``I understand there is a public desire for transparency and I don't want people to think things are being hidden from them," Dr. Richard Shemin, chief of cardiothoracic surgery at Boston Medical Center and president of the Massachusetts chapter of the Society of Thoracic Surgeons. ``Our fear is we'd hate to see a young surgeon who took too many risky cases be identified as a bad surgeon."

The state already releases the mortality rates at individual hospitals for cardiac bypass surgery and angioplasty, procedures used to treat clogged arteries. In bypass surgery, doctors create a new blood vessel, or route, around the diseased artery, while in angioplasty, they open the clogged vessel with a balloon and may insert a stent to keep it open. The state's data collection program has not found huge variations among hospitals, with the exception of UMass Memorial Medical Center in Worcester, which temporarily suspended its cardiac surgery program last year because of a higher-than-average mortality rate.

But the six-year-old state law that requires collection of death statistics leaves open the question of whether the state must report publicly mortality rates for individual cardiac surgeons and cardiologists, said Paul Dreyer, director of the Division of Health Care Quality at the Public Health Department. When the law was enacted, he and other officials decided against it, saying they believed it was better for state agencies and hospitals to use the physician data internally to identify poor performers and push for improvements.

Now, Dreyer said, officials have decided to rethink the question, largely because of the growing national push by employers, insurers, and politicians to disclose information about medical care that previously has been kept from the public or not collected.

Senator Mark C. Montigny, a New Bedford Democrat and a lead author of the legislation, said his intent was to give consumers access to mortality rates of individual doctors. ``The consuming public should be able to say that doctor so-and-so has this track record, and this is where I'm going to get my heart surgery," he said last week.

Advocates of public reporting believe that it holds providers accountable for the billions of healthcare dollars spent annually and helps patients decide where to seek treatment, creating market pressure on providers to improve care. This is especially important for common procedures like cardiac surgery and angioplasty, which are often planned for months in advance, giving patients time to shop around.

Doctors performed more than 4,393 bypass operations in Massachusetts in 2003, the most recent data the state has posted, and more than 12,657 angioplasty procedures from April though December of that year.

The idea of openness has flourished in Massachusetts. The Romney administration has established a transparency website where consumers can check how many times surgeons have performed 10 of the most common or complex operations, including hip and knee replacements and heart bypass surgery, among other quality and cost information. Most major insurers are posting the cost of common procedures on their websites. And the private, non profit Massachusetts Health Quality Partners provides performance ratings for 150 physician groups on its website.

Still, reporting mortality rates of individual physicians -- a measure that makes doctors nervous, because a bad number can ruin reputations and drive away patients -- is relatively new, and basic questions about its effectiveness remain unanswered.

New York initially released the results for hospitals in 1989, refusing to do so for individual doctors. But the newspaper Newsday successfully sued the state for access to the information, and the state began releasing death rates for doctors in 1991. Now, state officials credit the program with improving mortality rates for patients. In 2003, the most recent data available, New York's mortality rate for bypass surgery was 1.61 percent, compared to 3.52 percent in 1989. Massachusetts' mortality rate for bypass surgery in 2003 was 2.25 percent, though it's unclear whether the states' rates can be compared directly, because of differences in the way they're analyzed.

``The whole effort has led to better outcomes in New York State," said Edward Hannan, chairman of health policy management and behavior at University at Albany School of Public Health, who analyzes the data for the state. In some cases, hospitals refused to renew the privileges of poorly performing surgeons or those surgeons stopped performing the procedures.

But Massachusetts physicians who oppose public release of death rates for doctors see another reason for New York's improved mortality rate. They say that physicians, knowing their mortality rates will be made public, avoid performing procedures on high-risk patients, who are more likely to die, and refer them to doctors in nearby states.

``When you really start shining the light on individual doctors and their outcomes, then you really galvanize people who are worried about their results," said Dr. David Torchiana, head of the Massachusetts General Physicians Organization and a cardiac surgeon.

Several studies comparing cardiac patients in New York with those in other states have suggested that high-risk patients are leaving New York, Torchiana said. One recent study suggested that fewer patients suffering from shock following a heart attack, who are very high-risk, are getting angioplasty procedures in New York compared with other states.

But other studies have found the opposite, Hannan said, leaving the facts unclear.

Dreyer said public health officials are deciding this summer whether to release mortality data for individual doctors because they now have three years worth of data, 2002, 2003, and 2004, enough to be statistically reliable for doctors whose annual caseload is small.

Amy Lischko -- commissioner of the state division of Health Care Finance and Policy and the person in charge of the administration's transparency initiative -- said that health officials will try to convince doctors that publicly reporting the death rates is the right thing to do. But if not, said Lischko, the state is likely to go ahead anyway.

``It could be private the first year and then public the second year. That would be a reasonable compromise," she said. ``Eventually it will be public, unless someone comes out with a definitive study saying the information had a negative impact in New York. We're in an era where people want access to good information."