December 31, 2012
ALBANY(The New York Times News Service) -- Buried deep in the state Department of Health website lives a document that lists the number of open-heart surgeries each New York cardiac surgeon performs, and how many patients die. The report also discloses the doctors' names.
Most patients have never heard of the annual study, but going under the knife in New York is safer because of it.
"This is probably one of the most underreported and most valuable pieces of work that the Department of Health has been doing for decades and the people of New York have benefited as a result -- and no one knows of it," state Health Commissioner Dr. Nirav R. Shah said.
In 1988, the wide range of death rates for heart bypass surgery at New York hospitals disturbed then-Health Commissioner Dr. David Axelrod. Bypass surgery, also called coronary artery bypass graft surgery, is an operation in which a blood vessel from another part of the body is used to create an alternate path around a blocked artery in the heart. About 150 surgeons perform 10,000 bypass surgeries each year in New York.
In the late 1980s, mortality rates for the surgery were below 2 percent at some hospitals and over 10 percent at others. Hospitals with the worst rates claimed they had sicker patients.
Axelrod suspected quality issues were to blame, and he tapped a researcher inside the health department, Edward L. Hannan, to design a cardiac surgery registry to track patient mortality by age and health so the state could evaluate how well doctors performed the surgery.
A soft-spoken man with a doctorate in industrial engineering and operations research, Hannan took on Axelrod's task with passion. Today, he runs the $1.3 million cardiac registry from his office at the University at Albany's School of Public Health.
The cardiac registry received a lukewarm response from many doctors and hospitals. They feared the public would misunderstand the information, or that a random cluster of deaths would make a hospital look bad. Another worry was that surgeons would cherry-pick healthy patients and turn away risky cases to improve their results.
When the first report was published, in 1990, hospitals didn't expect an individual hospital or doctor's performance to be made public. Axelrod stunned the medical community when he gave a newspaper data on every hospital.
"It was on the front page of The New York Times with hospitals' names, and everybody went crazy," Hannan said.
Newsday sued for physician-level data, and two years later DOH released the death rates of each surgeon. New York had become the first state in the nation to release death rates for each hospital and physician.
The public scrutiny was motivating.
"Physicians are Type A personalities," said Dr. Ferdinand J. Venditti Jr., a cardiologist and vice dean at Albany Medical College. "They don't want to be outliers. They also want to do the best thing for their patients, so they take this stuff very seriously."
Hospitals at the bottom of the list quickly drafted improvement plans and shut down doctors with the worst records.
Between 1989 and 1992, 27 doctors who performed a low volume of open heart surgeries stopped doing the procedure entirely. Some were forced out, while some left voluntarily when they saw their numbers stacked up against those of their peers. Their departures were significant because numerous studies link low volumes to poor outcomes. Indeed, the combined mortality rate of the 27 surgeons was 11.9 percent, compared to the statewide rate of 3.1 percent at the time.
"The hospitals have even told us that they were glad they had this report to use as ammunition," Hannan said.
Venditti, the Albany Med cardiologist, said hospitals do not know how they compare to other hospitals without the state report. "You can have a 2 percent mortality rate and think, 'That's great,' only to find out the average statewide rate is half a percent."
DOH used the data to put some hospitals on probation, and state officials visited institutions with higher death rates. The agency also toured the top-performing hospitals and shared their methods with facilities across the state.
The mortality rate for bypass surgery in New York has been cut in half since Hannan first collected the data: The rate was 3.52 percent in 1989 and 1.58 percent in 2010, the most recent data available. Better surgical techniques and training have improved death rates nationwide, but the decrease in New York is larger, Hannan said.
"I personally believe that the public report and the quality-improvement efforts of DOH with this information is the cause," said Venditti, who also sits on the cardiac registry's advisory committee.
A handful of states -- New Jersey, Pennsylvania, California and Massachusetts -- have copied New York's cardiac report. But because most states do not track the outcomes of cardiac procedures, there is no reliable way to rank New York's performance against states nationwide.
However, Hannan's team conducted a 2003 study that used Medicare billing data to compare states that publicly reported mortality rates for open heart surgery to states that do not. The analysis found that patients in non-reporting states had a 52 percent higher chance of dying in the hospital during or shortly after surgery when compared to New York.
The state cardiac reports also include information on heart valve surgery and pediatric cardiac surgery. Angioplasty, which involves threading a catheter into the vessels of the heart to clear a blockage, was added in 1997.
The weakness of the reports, Hannan acknowledges, is how they are presented to the consumer. The data are bundled in charts that physicians understand but that the average patient might not. DOH archives the reports as PDFs in the depths of the agency's website with no easy way to search for a specific doctor or hospital.
"More needs to be done to get the data to consumers and make it understandable," Hannan said.
Shah, who is an advocate of data-driven quality improvement, would like to see more public reports for sepsis infections, pre-term births, elective Cesarean sections and other incidents and procedures.
"We need to continue to replicate this in every other area that is important to patients," Shah said. "It will force (hospitals) to continually improve their processes, or get out of the business."
Copyright 2012 The New York Times News Service. All rights reserved.