"There is a fear among health care professionals that as more states adopt mortality data reports, insurers may direct patients to hospitals with better scores, even though better scores probably do not correlate with better patient care."

Bad Marks

The anonymous poll was designed to measure whether the state Department of Health's system of tracking doctors' cardiac death rates had an impact on how doctors made treatment decisions -- and the types of patients they chose to accept.

The study, published in the January 10 issue of the Archives of Internal Medicine, found that 79 percent of New York interventional cardiologists polled responded that they made decisions about accepting critical cases into their cardiac catheterization labs that hinged on how the outcome would affect their state mortality data report card.

New York is one of only a handful of states to publish mortality data in an effort to raise consumer awareness about physicians' and hospitals' records, and more states are considering adopting the practice.

Many medical professionals, though, have long suspected that these report cards might influence some physicians to avoid taking critically ill patients to the catheterization lab, even though the patient might benefit from angioplasty, because of the possibility of adding a potential death to their files, says principal investigator Craig Narins, M.D., an interventional cardiologist.

Sixty-Five Percent Survey Response Rate

"While these reports attempt to provide the public with objective information about physician quality, they can in some instances create a conflict for the physician that may actually worsen patient care," Dr. Narins says says.

For the study, an anonymous one-page questionnaire was sent to all interventional cardiologists in New York -- 186 physicians -- who were included in the angioplasty report released in January 2003. They were asked to respond to nine statements regarding the state mortality reports, indicating whether they strongly agreed, agreed, disagreed or strongly disagreed with each statement.

The survey, which was conducted by Narins with Frederick Ling, M.D., Wojciech Zareba, M.D., Ph.D., and Ann Dozier, R.N., Ph.D., received an extraordinary 65 percent response rate. Investigators speculate that doctors responded in such large numbers because they wanted the public to know that a physician's mortality rate -- the only statistic measured on the state's report card -- is by itself an inaccurate indicator of the physician's skill level or quality of care.

Risk-Adjustment Insufficient

Of the 120 physicians who responded to the survey, the vast majority agreed or strongly agreed that the publication of mortality statistics has, in certain instances, influenced their decision regarding whether to perform angioplasty on individual patients. Physicians expressed an increased reluctance to intervene upon critically ill patients with high expected mortality rates, even though those patients might have the most to gain from angioplasty.

Among the respondents, 83 percent agreed or strongly agreed that patients who might benefit from angioplasty may not receive the procedure as a result of public reporting of physician-specific mortality rates.

The scoring system attempts to not penalize physicians as much when a more severely ill patient dies following a procedure; yet 85 percent of those surveyed believed that the risk-adjustment model used in New York was not sufficient to avoid punishing physicians who performed higher-risk interventions.

Lethal Numbers Game

The state reporting system may, as intended, lead some interventional cardiologists with low volumes or poor outcomes to improve their performance or stop performing the procedure. However, researchers say the unintended effects of the scorecard system on patient-care decisions, as described in the paper, may adversely affect outcomes for patients who might benefit from angioplasty but are denied the procedure.

"Take, for instance, a case of a very ill patient who presents to the emergency room with a large heart attack that is complicated by shock. Attempting to unplug the patient's blocked artery with an angioplasty procedure has been shown to save heart muscle and reduce the patient's chance of dying, but even if the cardiologist decides to perform angioplasty, some patients will not survive," Narins says.

"So the cardiologist must decide whether to perform a procedure that is possibly life-saving for the patient at the risk of making their own statistics ... look worse," he points out.

If the patient receives necessary angioplasty but ultimately dies from the illness, that death still shows up on the cardiologist's record. It counts not only against the doctor, but also against the medical institution when the state Department of Health releases cardiac mortality data.

However, if the cardiologist decides not to perform the angioplasty, which may increase the patient's chance of dying, there will be no impact on the doctor's statistics. Clearly, the presence of the report card may influence a doctor not to perform a procedure that could be helpful for the patient.

Better Scores, Worse Care

"There is a fear among health care professionals that as more states adopt mortality data reports, insurers may direct patients to hospitals with better scores, even though better scores probably do not correlate with better patient care," Narins says.

At the University of Rochester Medical Center, protocol dictates that all patients, regardless of their expected outcome, be treated in the cardiac catheterization lab if there is a chance they may benefit from angioplasty.

"Our numbers, although at times above the state average, reflect the deaths of patients who came to us critically ill," says Ling, director of the cardiac catheterization lab. "We're aware of the potential outcome, but it is our duty as physicians to treat patients to the best of our ability."