Cardiologists Say Rankings Sway Choices on Surgery

By MARC SANTORA

Published: January 11, 2005

An overwhelming majority of cardiologists in New York say that, in certain instances, they do not operate on patients who might benefit from heart surgery, because they are worried about hurting their rankings on physician scorecards issued by the state, according to a survey released yesterday.

The survey, which was sponsored by the School of Medicine and Dentistry at the University of Rochester, demonstrated the difficulty that many doctors have with the public disclosure of their performance data, an idea pioneered by New York State. In 1994, the state's Department of Health began to compile data on cardiologists performing coronary angioplasty, a less invasive procedure than bypass surgery for restoring blood flow to the heart.

Eighty-three percent of the cardiologists surveyed said that because the state reports the mortality rates of heart surgeons, patients who might benefit from angioplasty may not receive the procedure. In addition, 79 percent of the doctors said that the knowledge that mortality statistics would be made public had, at times, influenced their decision on whether to operate.

"I am really distressed by the responses we got from physicians," said Dr. Craig R. Narins, an author of a report on the survey. A practicing cardiologist, Dr. Narins said he was aware of general discomfort with the state's physician rankings but surprised by the degree to which doctors disliked the system.

According to the survey, about 75 percent of doctors said that the reports did not serve to improve patient care in the state.

Dr. Samin Sharma, director of interventional cardiology at Mount Sinai Medical Center, said he was not surprised by the survey's findings, given the hostility among many doctors to publicly releasing data of any kind. He added, however, that he believed the report cards had improved patient care in New York.

Dr. Sharma, who performs roughly 1,100 angioplasty surgeries a year but who did not take part in the survey, said that doctors who carried out a low volume of operations were the most likely to have their rankings skewed by a few isolated cases. But he said that complaints about the rankings would be lessened if the most severely ill patients, those suffering coronary shock, were taken out of the database.

Noting that New York State has the lowest mortality rates in the country for both angioplasty and bypass surgery, Dr. Sharma said, "What the report card has done is make us better interventionists, and better surgeons."

For the survey, Dr. Narins sent letters to 186 cardiologists ranked in the state's report, asking them to answer nine questions anonymously. Responses were received from 120 doctors - 65 percent.

Dr. Narins wrote that physician scorecards "exert an active influence on the clinical decision-making process of the physicians who are being assessed."

Dr. Narins said he was not opposed to the idea of publicly releasing information about the performance of physicians, but added that the current system was too simplistic.

"These databases equate mortality rates with quality of care," he said. "And mortality really does a poor job, in and of itself, in terms of determining the quality of care."

He said that surgeons often decided not to operate when patients were most at risk. Angioplasty, when performed as elective surgery, has a mortality rate of less than 1 percent. But when patients come to the hospital as they are suffering a heart attack, when their bodies are in shock and blood pressure is low, there is a 60 percent chance that they will die, Dr. Narins said. The chance of survival can be increased to 50 percent if surgery is performed.

Because the mortality risk is so great, these are the types of patients doctors are least likely to choose for surgery, Dr. Narins said.

"This issue is always in the back of our minds," he said.