The CFA Perspective

Physician Employment Isn’t Always Equal to Alignment

We have commented on this subject before (please see Physician/Hospital Integration and Pushback, posted April 22, 2011), but the issue was brought home to us recently by a client’s circumstances.  One would hope that when a hospital system merges with the largest multispecialty physician practice in their service area, a truly integrated system would be created and effective physician/hospital alignment would be achieved.  This is not necessarily so.  As we’ve said before, employment does not always equate to alignment; and alignment is not integration. 

 

This hospital system has a large, successful cardiovascular program staffed by a number of employed cardiologists. Some of the issues CFA found in the system were these:

 

• Lack of strong physician involvement, leadership and commitment to successful management of the program.
• Poor relationship between some physicians and cardiology staff leading to attitudes and behaviors that contributed to poor team-building and generally low morale.
• Lack of a high level of coordination of care and collaboration between cardiology, cardiac surgery and vascular services.
• Significant salaries with very limited pay-for-performance expectations in the employment agreements.
• Physician staffing issues, call schedules and other related issues.
• Less than consistently optimal levels of customer orientation and satisfaction.
• Challenges with procedure scheduling, patient through-put and operations efficiency.
• An overall service line culture described as “disempowering.”

 

In an attempt to obviate such issues, the health system has developed a document that delineates what is expected from each side in some level of specificity.  As evidenced by the presence of the issues outlined above, some physicians have not been abiding by this, nor in fairness, has the health system enforced it to the level it should.  As is frequently the case, this particular situation is somewhat unique with specific circumstances that have complicated both compliance and enforcement.

 

The challenging issues are certainly not unique to this health system, nor are they easy to deal with, but they are ones that can and should be addressed as part of any employment (or other alignment) situation if goal congruence and enhanced service line performance is to be achieved.  Setting reasonable and consensus-based employee expectations are a vital part of any employee/employer relationship and should not be significantly different when the employee is a physician.  Evaluating performance against expectations, particularly when agreed upon by both parties, should be a periodic and institutionalized process that insures both parties are given the opportunity to express their questions or concerns and reinforce expectations.  All employees should be held to the high standards of the organization. 

 

The CFA team invites your comments, suggestions and questions.

CFA’s New Book on Cardiovascular Service Line Strategic Marketing

With all that is going on in healthcare today, and the cardiovascular services environment in particular, why has CFA written a book on strategic marketing for the cardiovascular (CV) service line?  Because of our deep interest in and concern for the future of the cardiovascular enterprise and our collective feelings about how a sound marketing orientation and perspective is both undervalued and frequently underdeveloped in today’s hospitals.  Understanding the essence of marketing concepts, their specific application to CV service line development and planning and their fundamental role in the day-to-day management of the service line is critical to developing a high-performance enterprise, to earning buy-in from key constituencies and a return on your marketing investment. 

 

Here are some of the salient points that we make in the book, The Complete Guide to Strategic Marketing for the Cardiovascular Service Line:

• The overall premise of the book is that marketing, though not the institutional force it was when first widely introduced to hospitals in the 1980’s, still has much to offer the CV Service Line Administrator (SLA).
• Marketing philosophy, principles and practices have real value, particularly now, because of the evolving and challenging healthcare environment.
• Today’s healthcare trends and keys to success are largely driven by forces external to the hospital.  The strategic marketing process focuses on these external forces.
• Hospital administrative personnel, whether formal service line administrators or others responsible for cardiovascular programs and services can and should be fully capable of understanding marketing philosophy, principles and practices and implementing them in their everyday pursuit of enhanced service line performance.      
• The six major success trends outlined in the book support the premise that enhanced marketing capabilities at the service line level will strengthen and increase performance.
• Marketing’s role can be leveraged in the strategic management of the service line.
• Marketing tools, such as the marketing audit, positioning, brand management, market plan development and results monitoring, can produce tangible results.
• The effective use of social media can successfully position the CV service line for growth.
• An effective marketing self-assessment is an excellent way of evaluating the reader’s readiness and ability to implement a marketing philosophy.

 

The book is designed to augment philosophy, principles and practices with practical tools, straightforward ideas, real-world examples and case studies from CFA’s collective consulting experience in hundreds of hospital cardiovascular programs throughout the United States. 

 

The book can be ordered online at www.healthleadersmedia.com, or by calling (800) 753-0131.

 

As always, CFA invites your comments, suggestions and questions.  Already read the book?  Please leave a comment.  We would welcome your feedback.

HealthLeaders Media to Publish New CFA Cardiovascular Service Line Marketing Book

HealthLeaders Media (a division of HCPro), Brentwood, Tennessee, will publish a new book by CFA principals entitled, The Complete Guide to Marketing for the Cardiovascular Service Line. The book is now in the final stages of editing and should be published by the end of this year or early 2012.  Designed to fill an information gap for CV service line administrators (SLAs), the 200-page book will offer a comprehensive look at how marketing philosophy, principles and practices can assist in improving service line performance.  It is believed to be the first book of its kind, presenting a comprehensive approach to marketing specifically addressed to the hospital CV service line. The authors, John Meyer and Charles Franc, have laid out thirteen chapters of material, ranging from theory and practice through many application examples from the hundreds of cardiovascular clients served over the last 20+ years of exclusively cardiovascular consulting experience.

 

QA key premise of the book is that true marketing has been undervalued and misunderstood, and should be reconsidered and reemphasized in today’s health systems and hospitals, particularly at the service line level, where practical application of marketing can make a real difference.  The continuing evolution of the marketplace and competitive dynamics require that a re-emphasis be placed on marketing philosophy, principles and practices.  A market orientation is critical and fundamental to the hospital and the service line administrator in pursuit of corporate goals and objectives.  The book is intended to provide the CV SLA with enough marketing philosophy, principles and practices, augmented with ample real-world examples, to enable them to incorporate marketing into their daily management activities.

 

The book is divided into thirteen chapters, as follows:

 

1. Introduction
2. Fundamental of Strategic Marketing
3. Marketing’s Role in the Strategic Management of the Cardiovascular Service Line
4. Key’s for Success in the Coming Decade and Marketing Implications
5. The Marketing Audit
6. Planning and Developing New Programs and Services
7. Marketing Information and Research
8. Understanding and Using the Marketing Mix
9. Market Positioning, Differentiation and Branding
10. Web Presence and the Role of Social Media
11. Developing a Practical Marketing Plan
12. Marketing Self-Assessment
13. Conclusion   

 

CFA’s website will keep you up-to-date on the book’s publication date and availability, and we will post more blogs in the coming weeks and months featuring material from the book and relevant discussions of this important topic.

 

As always, CFA invites your comments, suggestions and questions. 

New Study Cites Safety of Same-Day Discharge for Elective PCI

According to a study recently published in the Journal of the American Medical Association, older, lower-risk patients undergoing elective PCI can be safely discharged from the hospital the same day as their procedure.  Although hospitals have begun to increase their same-day outpatient PCI rates over the last few years, among selected Medicare patients, same-day discharge is still relatively uncommon.  Study investigators observed nearly equivalent rates of mortality and rehospitalization at two and 30 days when compared with patients who stayed overnight.

 

The study concluded that there are a large number of patients who remain in the hospital overnight after PCI who could safely be sent home the day of their procedure.  Data was analyzed for 107,018 Medicare patients 65 years and older who underwent elective PCI and were contained in registries including those of the American College of Cardiology and Society for Cardiovascular Angiography and Interventions.  While the registries included many “straightforward” elective cases, more than one-third had a high-risk lesion, 16% underwent multiple vessel PCI and 12% had a bifurcated lesion.

 

Previous studies have focused on comparing early-discharge rates among patients undergoing PCI have been done outside the U.S. using radial access or single center studies with femoral access and vascular-closure devices.  Radial access has generated considerable interest (see CFA’s blog on radial access posted on March 31, 2010) so there was considerable interest on the part of researchers to ascertain whether it was necessary, regardless of access site, for PCI patients to remain in hospital overnight.

 

The overall prevalence of same-day discharge was 1.25%, and there was significant variation across different centers in the registry.  Rates of death and rehospitalization between the two groups were statistically similar.  The principal investigator opined that “…we need to get better at stratifying high- and low-risk patients.  When we looked at the lower-risk patients in the study, many are remaining in the hospital overnight.  In this case, the physician is probably unable to figure out who should go home early, so they keep everybody.”

 

Treating low-risk PCI patients as same-day outpatients would result in shorter stay, less overhead and less occupancy of a hospital bed.  CMS pays for outpatient PCI (defined as less than a 23-hour stay) and has criteria to determine who should stay overnight.  Overhead costs would also be impacted by the approach, femoral or radial.  The ideal candidate for early discharge is a patient who had successful PCI and does not require prolonged IV medications, prolonged bivalirudin infusion or prolonged monitoring for other reasons.  The patient should be ambulatory within six to eight hours and have adequate home support, including ability to return to the hospital in case of emergency.  Of interest, the principal investigator’s hospital, Duke, does not discharge patients at night or those who live more than 60 miles away from the nearest hospital.

 

CFA recommends that hospitals consider same-day outpatient PCI for appropriate patients and evaluate this with their interventional cardiology staff.  Included in this discussion and evaluation would be issues of patient selection, risk stratification, femoral/arterial approaches, recovery site and attendant processes, discharge criteria, patient support system post-discharge and the resulting documentation of cost savings and clinical outcomes.

 

For further information, refer to Rao SV, Kaltenbach LA, Weintraub WS, et al.  Prevalence and Outcomes of Same-Day Discharge after Elective Percutaneous Coronary Intervention among Older Adults.  JAMA 2011:  306 (October 5, 2011):  1461-1467.

 

CFA invites your comments, suggestions and questions.

Cardiovascular Specialists and the Patient-Centered Medical Home Model

 

Over the last few years, there has been a keen interest in the patient-centered medical home (PCMH) model of care, highlighted by its prominent inclusion in the Patient Protection and Affordable Care Act (PPACA).  The framework for the model was created years ago by the American College of Physicians and endorsed over time by many professional societies and medical professional associations including the American College of Cardiology (ACC).  It has also been promoted by labor unions, health plans, consumer groups and large businesses.  The Commonwealth Fund has identified seven attributes necessary for patient-centered care:

 

1. Access to care;
2. Patient engagement;
3. Clinical information systems that support high-quality care, practice-based learning and quality improvement;
4. Care coordination;
5. Integrated and comprehensive team care;
6. Routine patient feedback to doctors; and
7. Publicly available information.

 

The above attributes sound like logical and commendable goals that any physician practice should strive for.  The problem is in the details, and ultimately, in what physicians get reimbursed.  The PCMH model is viewed almost universally as a primary care-centric model, although who constitutes a “Primary Care Practitioner” is currently not well defined.  How do specialists fit the model?  It assumes that internal medicine-trained specialists such as cardiologists, although capable of being the principal physician in a PCMH model, would not readily choose this role.  Specialists are justifiably concerned that reimbursement dollars will be shifted away from their specialties towards primary care under a fully-implemented PCMH model.  Additionally, the treatment of chronic medical conditions figures prominently in coverage plans and therefore impacts specialists like cardiologists who are expert in treating chronic illnesses such as advanced congestive heart failure and chronic cardiac arrhythmias.  Key question; how many “primary care” patients do cardiologists see in their practices?  Is the PCMH concept for these specialists even an issue?

 

Research suggests it may not be an issue at all.  The New England Journal of Medicine published Specialist Physician Practices as Patient-Centered Medical Homes, in April 2010, in which they conducted a telephone poll of selected specialists (including 207 cardiology practices) to answer the question, “…for approximately what percentage of patients, if any, do the physicians in your practice serve as primary care physicians as well as specialists?”   In 86% of surveyed cardiology practices, physicians served as primary care practitioners for 10% or fewer patients.  According to their own report, the overwhelming majority of cardiologists provide primary care for very few or none of their patients.  However, a minority do provide some amount of primary care.  Please see the summary table with this information.

 

Despite this seemingly minor impact, the ACC has established initiatives to keep cardiologists from being per se excluded from participation as a medical home, including the establishment of the CardioSmart.org website, and the Patient-Centered Care Committee (PC3), charged with “transforming the patient care experience and improving health outcomes for people with heart disease through development of partnerships, programs and tools that support care …”  It seems that their fear is twofold:  1) that the model will downplay the role of specialists (to save money); and 2) that PCP’s will manage complex CV-related chronic conditions, to the detriment of the patient and the financial health of the specialist.

 

Whether or not cardiologists will choose to participate in the Medical Home model is certainly debatable.  If they do participate, they will undoubtedly be held to the high standards established for PCPs.  This will include the standard of care they now provide, plus …”proactively, systematically and in an organized manner, trying to improve the health of the population of patients within a practice…” using healthcare information technology (sharing data among providers), nurse care managers and other disparate resources.  Compliance with these requirements of participation will be a significant challenge for any practice, but particularly challenging to cardiologists and other specialty practices!

 

CFA invites your comments, suggestions and questions. 

Coronary CT - Why Isn’t its Usage Soaring?

Why hasn’t coronary CT angiography (CCTA) really taken off as a chest pain triage strategy?  Or, as a final stage, pre-cath noninvasive screening tool for certain patient populations?  The potential benefits and cost savings associated with CCTA have been recognized and well documented.  Clinical studies and research papers continue to tout its cost effectiveness and clinical efficacy.  Yet since the advent of the ultrafast, 64-slice CT era began, its increased use has been slow – painfully so to those who promoted its use only a few years ago.

 

A perceptive article appeared in the November 2010 issue of Diagnostic Imaging.  Dr. David A. Dowe, medical director of the coronary CTA program at Atlantic Medical Imaging in Galloway, New Jersey, an early proponent of CCTA, offered his thoughts in an opinion piece entitled, “Coronary CTA really works, but why isn’t its use soaring?”  In an accompanying editorial entitled, “The deck is stacked against coronary CTA: why it matters,” the journal’s editor, John C. Hayes, weighs in support of Dr. Dowe. 

 

Dr. Dowe proposes that despite all of the positive attributes of CCTA, the following factors have negatively impacted its use:

• The Radiation Dosage Scare – The uproar over radiation exposure from medical imaging tests kicked off a national debate over dosage that spilled out into CT.  CT volumes dropped up to 20% in the outpatient setting.  CCTA, which in original form exceeded the radiation doses commonly quoted for catheter-based angiography, was affected even more as it became a political football by those who wished to maintain the status quo.
• Radiology Business Management Companies and Insurance – The explosion in medical imaging volume and costs is well known.  For real or perceived reasons, this has put imaging in the crosshairs of the insurance industry, which moved aggressively to confront the problem.  Insurance companies contracted with Radiology Business Management Companies (RBMs) to pre approve all imaging scans.  RMBs have not accepted CCTA as cost effective given underlying competing economic motives.  RMBs may be reimbursed by how well they decrease utilization, or participate in risk contracts where their fee is determined by how far they drive down prices.  In addition, the shift of copayments from employers to employees has caused some patient copayments for advanced imaging such as CCTA to soar.
• The Radiology-Cardiology Turf War – There exists an ongoing dispute between radiology and cardiology over the ownership and use of CCTA that has resulted in disagreements over ownership, control, training, certification and usage.  Additionally, there is some level of disagreement among cardiologists over the appropriate usage and cost effectiveness of CCTA.  To quote Dr. Dowe, “It is an internal conflict, which mixes both medical and economic considerations that are seized upon by the insurance/RBM industry as a reason for not approving any utilization of CCTA.  They have a ‘Call me when you agree’ attitude.”  Various regulatory and payment mechanisms have continued to address physician self-referral, which impacts cardiologists owning CCTA and supports radiologists grabbing CCTA market share (but then is a disincentive for cardiologists to refer patients to radiology for the test rather than use alternative testing which they themselves control).

 

Dr. Dowe concludes that it is not clinical efficacy that is the problem with CCTA usage, but rather a host of outside factors that have embroiled and sidelined it, and the result has been less effective care.  It will be interesting to see how this issue plays out over time and whether or not health care reform has any impact.

 

As always, CFA invites your comments, suggestions and questions. 

The CFA Perspective: Physician/Hospital Integration and Pushback

If hospitals are going to align with physicians, most, given the ability, might choose to employ every physician on their medical staff.  However, in many cases, hospitals and health systems will end up with alignment strategies that encompass physician employment, arrangements including joint ventures, co-management agreements and other hybrids, combinations and permutations that have yet to be dreamed up!  The healthcare field is simply too complex to produce a one-size-fits-all circumstances solution.  Some physicians will choose to reject alignment and compete – or accept alignment elsewhere and compete!  The future medical staff will be a hybrid along the alignment continuum and look very different than it does today.

Another reality of an alignment strategy is pushback and other forms of retribution or overt competition on the part of some members of the medical staff towards the hospital that is promoting alignment.  Physicians who are non-aligned (through their own choice or through “non-selection”) may view this strategy as exclusionary, discriminatory, and anti-competitive, and take legal or other actions against the hospital, its administration, and/or other members of the medical staff.  Legal action, redirection of referrals and non-participation in hospital business or clinical activities has occurred.  Some physicians have gone into open competition with their aligned colleagues and with the aligning hospital.

 

Hospitals have taken a very diverse approach to pushback and competition.  A hospital may take the high road on competition, believing that its alignment approach will ultimately create a relationship that is more valuable and sustainable than one where physicians go into competing enterprises:  they simply wish them good luck and try to ignore them.  Other hospitals have taken a hard line, denying privileges to physicians that invest in or take their patients to competing facilities such as heart hospitals.   One hospital took a serious hit in patient referral volume when some staff cardiologists decided to punish it for establishing a California-legal medical foundation by filing a lawsuit to overturn the foundation and referring patients to other local programs.  At the time the foundation was started, it had no cardiologists as members and the local cardiologists were invited to participate!  The hospital was then put in the position of having to recruit new cardiologists to serve the community and rebuild the cardiovascular program.

 

Physicians may have opportunities to participate in multiple joint ventures with competing hospitals or systems.  Most hospitals will make them choose sides without coercion or threat – just persuasion based on the mutuality of interests.

 

Pushback isn’t just about nonaligned physicians.  For example, if an aligned group of cardiologists practices at more than one hospital, what happens when the competing hospital (or hospitals) shuts them out of call schedules, directorships and the like?  Should this have been anticipated during the integration process by the parties?  And how should their compensation package account for this likely scenario, if at all?

 

As has been said many times, healthcare is messy and complicated.  Any hospital contemplating an alignment strategy must consider the potential negative consequences of action by non-aligned staff and develop appropriate strategies to deal with these actions.

 

As always, CFA welcomes your comments, suggestions and questions.

The Re-emergence of the Center Of Excellence

Will the passage of the Patient Protection and Affordable Care Act (PPACA) in 2010 usher in a renewed emphasis on hospital Centers of Excellence (COE)?  Did the Center of Excellence concept ever really go away?  Whatever you call it, and most importantly, however you define it, the COE remains a logical concept for organizing, staffing, marketing and focusing resources on a relatively homogenous patient population of great importance to the typical hospital.  This has been particularly true with comprehensive cardiovascular services, as they comprise a highly visible clinical service frequently contributing significant revenue to the hospital or health system.  Successful CV programs require focused management, significant and regular capital investment in expensive technology, ongoing clinical development and a large and diverse specialty medical staff.  Are these programs comprehensive CV service lines or CV Centers of Excellence?  CFA believes that the most successful programs are nearly indistinguishable.

 

One way to interpret the intended consequences of the PPACA is the push towards a number of new payment incentives that require a closer working relationship between physicians and hospitals.  These include accountable care organizations (ACOs), pay-for-performance-type programs, payment bundling (hospital and physicians), and several other initiatives.  If hospitals need to work more closely with their physicians towards achieving common objectives, then what better way to organize this effort than around a specific service line, or Center of Excellence?  With healthcare reform promoting better health outcomes at lower cost, it makes sense that hospitals look at the best way to approach their individual strategic and operational response to reform. 

 

COEs are a logical place to start.  Currently, while cardiovascular specialists focus their attention on the service line that supports their work, their level of engagement varies.  COE development can be promoted by enhancing physician/hospital integration.  Specialty physicians can be expected to work more closely within their respective hospital service lines to promote increasing value to patients and payers when they are incentivized to do so.

 

Focus on COE development will parallel the needs of the developing PPACA-sponsored efforts.  Physician-hospital alignment and comprehensive integration can create the mechanism for goal congruence and appropriate incentivization towards these goals.  Alignment/integration strategies must focus on how these strategies will successfully support the goals and objectives of the service line.

 

Beyond fostering closer integration and alignment with the CV medical staff to better respond to emerging requirements of the PPACA, CFA believes that eventually governmental payers will contractually steer patients to the higher quality and lower cost providers (as many private payers/managed care plans do today).  This eventuality will be driven by the necessity for Medicare and Medicaid to achieve substantial cost savings in the face of increasing demand for services by our aging population.  Preparing and positioning to respond to such a heightened competitive arena will likely drive CV COEs to re-double their program development and management efforts to new levels.  This is what CFA calls a Performance-Based Center of Excellence.

 

We will leave the discussion of what is required to turn a service line into a “Performance-Based” Center of Excellence for a future article.

 

CFA invites your thoughts, comments and questions.

SYNTAX Trial – Is CABG Underused?

We were recently discussing our years in the field of cardiovascular medicine and one of my colleagues vividly remembered the day our hospital performed its first percutaneous transluminal coronary angioplasty (PTCA) more than 30 years ago.  Our cardiovascular program was very early adopting the technology which required the hospital to send two of its best soon-to-be “interventional” cardiologists to Switzerland to learn the procedure directly from Dr. Andreas Gruentzig himself.  A new day dawned and the development and inevitable ascent of percutaneous coronary intervention (PCI) began.  With the rapid dissemination of this new technology, and the eventual addition of coronary drug-eluting stent technology, cardiologists had a new, clinically effective and cost effective tool that obviated at least some patients from having to undergo coronary artery bypass graft (CABG) surgery.  As it turned out, a lot of patients have avoided CABG since then!  According to the National Center for Health Statistics, PCI increased from about 561,000 patients in 2000 to about 1,313,000 patients in 2006 (up 134%).  CABG began its concomitant decline in volume from a high of about 607,000 patients in 2000 to a low of about 448,000 patients in 2006 (down 26%).  Not-so-gradually, a less-invasive, less expensive and safer procedure was able to eliminate a large number of more costly surgical procedures with considerably higher risks and recovery implications.  A good thing, right?

 

Maybe not.  The SYNTAX Trial (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) the first large trial to compare stenting and CABG directly, first reported in early 2009, has continued to stir the controversy.  The trial randomized 1,800 patients (in Europe and the U.S.) with severe CAD to either CABG or drug-eluting stents, and followed them for twelve months thereafter.  On September 12, 2010 in Geneva, additional results were reported.  The researchers conclude that tens or even hundreds of thousands of Americans are having coronary artery angioplasty and stenting every year when they should be having CABG, and the result is an extra 5,000 or more deaths annually.  The trial randomized patients with severe CAD -- triple-vessel or left main disease.  This group has remained nearly the only subset of patients that cardiologists feel compelled to refer for CABG surgery.  It has been suggested that cardiologists have long been desirous of trial results that would show that stents are just as good as CABG even in these patients.

 

SYNTAX seems to prove otherwise. Three years after the procedure, those that received a stent procedure were 28% more likely to suffer a major event such as a heart attack or stroke, and 46% more likely to require a repeat revascularization.  They were also 22% more likely to have a mortal event.  It seems that, for the most severe disease, surgery has a real patient advantage.   For patients with mild disease, the two procedures offer equivalent results.  But the differences were much more dramatic for patients with more severe CAD.  Approximately 50% of all patients undergoing angioplasty in the U.S. have more severe disease.  Hence, the researchers conclusion that CABG is underutilized for patients in this category.

 

While surgeons have touted these results, some cardiologists continue to believe that some patients with severe CAD should still be considered candidates for stenting despite the results of the trial.  They argue that some of the “endpoint events” in the study, such as the rate of stroke (lower in stents than in CABG) are more important than others and work in coronary stenting’s favor.  To this end, the SYNTAX investigators are working to develop a “SYNTAX score” that would help physicians determine which patients would benefit the most from which procedure.  It seems inevitable that additional clarification will be produced; guidelines, protocols (and perhaps even governmental and/or insurance company dictates) will be produced to reflect the SYNTAX conclusion.  Cardiac surgeons may be happy, but how far will these results go in settling this issue with cardiologists and their patients (let’s not forget the need for a well informed patient in all this), and how will this impact CABG volumes over the next few years?  Despite SYNTAX, the struggle between competing procedures and competing specialists will surely continue.  Well designed research should clarify and enlighten.  Unfortunately, no matter how good the research and compelling the findings, sometimes enlightenment is often a difficult end point to achieve.

 

CFA invites your thoughts and comments.

Public Release of Online CABG Report Cards

On September 7, 2010, Consumer’s Union (publisher of Consumer Reports) reported the results of coronary-artery bypass graft (CABG) procedures at 221 surgery programs (about 20% of U.S. programs).  Matched with a Perspective article in the September 9, 2010 issue of the New England Journal of Medicine online, which described this voluntary reporting as a “watershed event;” thus having enormous implications for hospital CV programs.  The data derive from the Society of Thoracic Surgeons (STS) database used by 90% (1,100) U.S. cardiac surgery programs.  Each volunteering program is now rated one, two or three stars based on an analysis of eleven performance measures endorsed by the National Quality Forum (see the article for a complete listing of outcome measures – they should be familiar to everyone).  The ratings depend upon whether the risk-adjusted outcomes in a program fall below, are equal to, or exceed the average performance range. 

 

STS data has historically been closely held by its participating hospitals and surgeons.  This effort on their part to make it transparent will be widely debated.  The ratings have their shortcomings.  They are voluntary, and typically only those with good ratings have released the information (50 programs that received three stars released data while only 5 with one star released their information).  This effort begs real questions of how valid such rating systems are in helping consumers choose between competing programs, and whether voluntary or mandatory systems are optimal.  However, the mounting consumer (and governmental) pressure for transparency was instrumental in bringing this rating system to completion.  The oft heard complaint of physicians, that such data is not valid, is countered with the voluntary release of data from participating physicians themselves under the imprimatur of their own professional society (the STS) which has been highly rigorous in testing its validity.

 

The authors conclude with the following comments:

 

• Regardless of the approach taken to transparency (voluntary or mandatory), public reporting will increasingly be a fact of life for physicians.
• The approach taken by the STS can be applied to other initiatives aimed at bringing performance data derived from clinical sources to the public (and thereby reducing the time and expense involved).  Other professional groups (e.g., vascular surgeons) are surely next.
• This experience may contain lessons for the Center for Medicare and Medicaid Studies as it prepares to handle the sea of new clinical data mandated under programs such as the Physician Quality Reporting Initiative and the “meaningful use” requirements for electronic health records.

 

CFA strongly concurs with the first bullet – public reporting is here and will increasingly be a part of every hospital and cardiovascular physician groups’ daily lives.  CFA’s earlier blog posting – The Best Measure of Outcome is Outcome – published on our website Thursday, March 18, offered recommendations for dealing with Volume/Outcome issues that are generally applicable to the CABG data as well.  

 

CFA refers you to www.nejm.org for the Perspective article:  Public Release of Clinical Outcomes Data – Online CABG Report Card – which is a free download.  Additionally, the 50 Top Rated Surgical Groups in the U.S. was published in Consumer Reports, October 2010 issue. The complete ratings are available at http://www.consumerreports.org/health/doctors-hospitals/heart-surgeons.htm (although the actual scoring can be reviewed by website subscribers only).

 

What do you think?  As always, CFA invites your comments, suggestions and questions.