Bioethics Discussion Blog: Putting Doctors on a List:Good Idea or Bad To Fool Around with Human Nature?

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Monday, January 28, 2008

Putting Doctors on a List:Good Idea or Bad To Fool Around with Human Nature?

The idea is how to develop even better and less expensive medical care than what we already have. We have discussed this issue previously on a thread titled “Pay for Performance: Doctors, Hospitals and Pills” . I wrote “Would you like to see all doctors and hospitals required to follow protocols and achieve benchmarks for the results of treatments based on evidence based medicine studies or statistically achievable norms? Should their report cards be made public regarding how well they are following the rules and how well they are doing?

Would you like to select from a list of doctors and hospitals who are better than others and know which doctors and hospitals one should avoid? Should doctors and hospitals be paid by patients, insurance companies and the government based on where on the list of acceptable performance they are located?”


Well, the State of New York has been preparing lists, available to the public, that deal with the results of the treatment by cardiologists and surgeons for heart attacks. But perhaps there is something about human nature that has to do with discomfort with lists and so some doctors will attempt to see to it that they do not end up near the bottom of the list by manipulating selection of their patients, such as not taking on high risk patients, rather than taking on all patients who need treatment and simply try their best to do a good job.

Here are the results of a study regarding the New York state listing which was published in the February 2008 issue of the American Heart Journal by A.P. Apolito and others titled “Impact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock.” Patients who have heart attacks and whose blood pressure has fallen due to the heart attack are at greatest risk of dying irrespective of the treatment. The conclusion: “New York patients with acute myocardial infarction and cardiogenic shock were less likely to undergo coronary angiography [dye visualization of the arteries of the heart] and PCI [opening of the blocked coronary artery with a catheter] and waited significantly longer to receive CABG [bypass graft heart surgery] than their non-New York counterparts. These findings suggest that state-required reporting to the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System may result in the reluctance to revascularize the highest-risk cardiac patients.”

After all, its human nature to try not to be a loser, perhaps even amongst doctors. Does this study, confirming previous studies and if further confirmed with other surveys, tell us something about the idea to make lists or also something about the medical profession?

3 Comments:

At Tuesday, January 29, 2008 9:14:00 AM, Anonymous js md said...

It's the law of unintended consequences hard at work. Of course the lists have a profound effect on physician behavior.
I believe that there is evidence, but I don't recall whether it is anecdotal or published that NY surgeons routinely turn down high risk patients for open heart surgery because of the lists. They probably do have an adjustment for severity but I don't know how well it works to equalize the results. In these times of falling rates of heart surgery, surgeons may not be willing to take the risk of being low rated.

 
At Tuesday, January 29, 2008 1:38:00 PM, Anonymous Anonymous said...

The interesting question is whether survival rates are lower in NY. Perhaps the lists just eliminate unneccessary defensive medicine.


Less is more, it seems in medicine, at least that's what the Dartmouth studies tell us.

 
At Tuesday, January 29, 2008 3:42:00 PM, Anonymous js md said...

I should add that I'm referring to previous data I saw on the subject from New York. This is an unintended consequence, but it was not an unforeseen consequence. It was highly predictable.
There is also lots of talk about rating doctors by how well they manage their patients. Some of this is just a ruse by insurance companies to keep down costs, but whether or not you can fairly measure quality and not cost, there will be a price to pay. Physicians will avoid taking care of poorly compliant or high risk patients. It would be a double whammy, taking the extra time with difficult patients only to have your whole practice downgraded financially or criticized publicly.

 

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