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Patient Safety and Quality

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Cardiac surgeons are not reluctant to treat high-risk cardiac patients who may tarnish their quality scorecards

In an era of public physician and hospital scorecards, there is growing concern that cardiac surgeons may hesitate to operate on high-risk patients, who might lower physicians' quality rankings due to increased heart surgery mortality rate. However, a new study allays those concerns. It shows that high-risk coronary artery bypass graft surgery (CABG) patients are significantly more likely to receive care from high-quality surgeons compared with lower risk patients, even after adjusting for patient race and ethnicity.

Laurent G. Glance, M.D., of the University of Rochester Medical Center, and colleagues analyzed data from the New York State Cardiac Surgery Reporting System. This database included all patients undergoing CABG surgery in the State who were discharged between 1997 and 1999. The study sample included 57,150 patients treated by 189 surgeons at 33 hospitals, who had an overall 2.2 percent mortality rate.

The researchers examined the association between surgeon quality {observed-to-expected (given the patient's condition) mortality ratio} and patient risk of death (using 30 risk factors such as other coexisting diseases and previous open heart surgery). They found no evidence that high-quality surgeons selectively avoided high-risk patients. For every 10 percentage point increase in patient risk of death (for example, from 5 to 15 percent) there was a 0.034 reduction in the surgeon observed-to-expected mortality ratio. Even within the same hospital, higher risk patients still tended to be treated by higher quality surgeons.

The researchers call for more research to better understand the underlying mechanisms for these findings. Their study was supported by the Agency for Healthcare Research and Quality (HS13617).

More details are in "Are high-quality surgeons less likely to operate on high-risk patients compared to low-quality surgeons? Evidence from New York State," by Dr. Glance, Andrew Dick, Ph.D., Dana B. Mukamel, Ph.D., and others, in the February 2008 HSR: Health Services Research 43(1, Part I), pp. 300-312.

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