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Eur J Cardiothorac Surg 2003;23:607-608
© 2003 Elsevier Science NL
Cattedra di Cardiochirurgia, Università di Roma Tor Vergata, European Hospital, via Portuense 700, 00149 Rome, Italy
Received 18 December 2002; accepted 20 December 2002.
* Tel.: +39-6-659-759; fax: +39-6-6597-5724
e-mail: depauli{at}tin.it
Key Words: Coronary artery bypass surgery • Discharge abstract data • 30-Day mortality
There is no doubt that the publication of performance data of different cardiac surgery units is an effort toward an improvement of the quality of care to better serve the final consumer (i.e. the patient). Quality comparison is in fact mostly intended to stimulate internal quality improvement efforts by physicians and health care providers but is also used as a mean to control and contain costs. Nonetheless, several implications are related to such reports and interpretation of the data are often not univocal and subject to debate. The responsibilities of such reports are important because they can affect future decisions making at several levels. While these studies are expected to positively influence the delivered quality of care as demonstrated in some of the pioneering studies in this field [1], on the other hand they could negatively influence the decision whether or not operating on sicker or elderly patients, with restriction from surgical activities for resident in teaching hospitals, or the decrease of operating privileges for less experienced, low-volume surgeons. Health care providers of good performing hospitals would probably use such information to attract more patients or use it as a benchmark for obtaining more resources and financial support. Conversely, publications of data of poor performing hospitals would probably have a negative impact on citizens confidence and on the professional reputation of the people involved. In this respect this type of studies needs to be very accurate: the exactness and completeness of the collected data, the quality control of the collected data, the quality control of the study database, the definitions of co-morbidities and the risk stratification are among the most critical aspects that should be explored thoroughly. After the reports is published, it is difficult that the reader would go into such technical details but his attention would rather be focused on the outcome analysis.
Crude mortality rate often served as indicator of quality of care but it is of limited value without knowing the risk profile of the patients [2,3]. Non-risk stratified data are incorrect and misleading and their publication should strongly be avoided. Analysis of the EuroSCORE database [4] on 19 030 European patients showed that a great number of cardiac factors contribute to surgical mortality. In the absence of any risk factor, the baseline mortality for isolated coronary artery bypass grafting was found to decrease from 3.4 to 0.4% implicating that the absolute risk of the processes and structure of care is almost absent. Therefore, the profound impact of patients risk profile on the outcome should guide any study aimed at predicting mortality or at assessing quality of care.
In the context of monitoring quality of care, Agabiti et al. in this issue of the Journal report an elegant study on the use of an hospital information system (HIS) for screening cardiac surgery units with different performances. Discharge abstracts were used to collect data as they are readily available, have a low cost, and cover a great number of patients.
This study has the merit of being one of the first attempt in Italy to demonstrate the inherent potentiality of administrative data. It is also evident how the authors have used at their best the data that were available. However, HIS data have not been validated and might not be sufficiently sound as the quality of the discharge abstract data might vary from the different centres [5]. The fact that the percentage of the reported complications does not correlate with the hospital stay is unusual and is probably an example of under- or over-reporting. Therefore, complications rate should not be used to validate the hypothesis of different quality of care. Furthermore, because of the source of the data, some of the risk factors that are usually present in most of the clinical data sets which served for risk-adjusted outcomes programs [6–10] could not be considered. In particular, the authors did not include the impact of some preoperative risk factors among others like previous cardiac surgery, neurological dysfunction, cardiogenic shock, New York Heart Association status, ejection fraction or operative factors like urgent or emergent operation that have proved to be strongly linked with cardiac surgical mortality. Finally, their risk model was derived from a relatively small group of patients and reapplied to the same population without validation. It is already well evident that inclusion of some risk factors (models 2 and 3) significantly reduced the difference among hospital A and the other hospitals. Would these differences be further modified by including all risk factors? A final consideration would be the appropriate timing of such reports. Apart from verifying the methodology of the HIS as a screening tool, what is the value of publishing data 5 years after their collection? At this stage the published data might not serve as a stimulus for improving the quality of delivered care. In fact, health providers seems to be the most responsive to the performance data. A recent survey on reporting systems evaluated in peer review publication [11] demonstrated that patients and individual corporation rarely seek for such information and seldom use it or trust it while physicians are often sceptical and do not usually discuss it with their patients. Conversely, hospitals were found to implement process improvements especially if located in competitive environments, and used the performance data for ameliorating coding, educating staff and improving outcomes.
Quality control studies are also needed in response to the cost-containment issues that is of growing importance independently from the type of health care financing system. Nowadays decision making on technology and resource as well as human force utilization are no longer in the hands of the physicians. Non-medical decisions could therefore affect the quality of care delivered by a single or by a group of physicians. Indicators of good quality of care should therefore be clearly described so that the additional cost of a given procedure could be appropriately defended. Similarly, expensive and ineffective interventions could be more readily avoided. In this light the important role of the physician in guiding any cardiac outcomes reporting program should be underlined. A recent pilot study demonstrated how a physician governed cardiac outcome registry was successful in ‘balancing the informational needs of the medical community with those of regulatory bodies’ [12].
There is an increased need for reliable information about the quality of delivered care. Despite some criticisms these data should be actively pursued for their continuous positive impact on internal quality control analysis. However, an even strenuous effort should be directed in assuring that the methods and the data used to generate such reports were independently evaluated and validated.
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