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Why Choosing the Right Surgeon Matters

surgeryFew hospitals in America are more highly regarded than Johns Hopkins, which U.S. News & World Report ranked No. 1 in the nation 21 times in a row between 1991 and 2011.

Hopkins is also home to the Armstrong Institute for Patient Safety and Quality, led by Dr. Peter Pronovost, among the best-known and most influential voices in the patient-safety movement.

So it was surprising to discover that, according to ProPublica’s analysis, a surgeon with an unusually high complication rate for prostate removals practices at Johns Hopkins.

Dr. Misop Han, an associate professor of urology and oncology at the Johns Hopkins Hospital, did prostate removals on 86 Medicare patients in ProPublica’s analysis between 2009 and 2013. A dozen of them had complications, our analysis showed. Adjusting for his patient mix and other factors, Han’s complication rate was 7.6 percent.

That was more than double the national average for prostate removals in Medicare and three times higher than the average for other surgeons at Hopkins, who had excellent results overall. Three of Han’s colleagues had complication rates low enough to rank in the best 5 percent nationwide, ProPublica found.

Han declined to respond to questions about his results. He is generally held in high esteem at Hopkins. Dr. Alan Partin, the chairman of the urology department, said in an email that Han is “one of the best surgeons I know.”

In interviews and emailed statements, officials at Johns Hopkins insisted that by their measures Han’s outcomes were “acceptable” and “do not differ significantly from his peers” at the hospital. “His numbers are all within the expected limits,” said Dr. Redonda Miller, the hospital’s vice president of medical affairs.

The hospital said it tracks surgeons’ performance using a variety of methods, including readmissions to Hopkins for any reason, even those unrelated to surgical procedures.

Hospital officials said a review of Han’s prostate removal procedures between 2009 and 2013 showed his readmission rate for all patients — Medicare and non-Medicare — was 4.7 percent. According to Hopkins, Han’s readmissions peaked in 2010, when he had 10 in 93 cases, a rate of 10.8 percent. Hospital officials did not specify his readmission rates for the years that followed, but indicated they had dropped.

By these measures, however, Han’s performance still appears below average. Nationally, typical readmission rates for the type of surgery Han most often performed on Medicare patients are about 3.6 percent, according to two recent studies.

Hopkins said ProPublica’s assessment of Han was skewed by its reliance on Medicare data, which omits hundreds of Han’s procedures that were paid for by private insurance. The hospital’s data shows that his readmission rate for Medicare patients was 8 percent, twice that of his non-Medicare patients. The Medicare cases, the hospital said in an email, are “hardly a statistically robust sample.”

But compared to other surgeons in Medicare, Han performed enough operations resulting in complications to conclude with 95 percent certainty that he was an outlier, ProPublica found.

Hopkins officials acknowledged their overall readmission rate for Han reflected readmissions only to Johns Hopkins. But there were additional instances in which Han’s patients were readmitted to other hospitals — cases that Hopkins would not have counted. ProPublica can’t say how many because Medicare patient-privacy rules bar reporting any count of patients between zero and 11.

In interviews last year, Pronovost praised ProPublica’s approach for calculating surgeons’ complication rates, saying it “advanced the field.”

More recently, though, he blasted our findings. “It would be highly irresponsible to present this to the public in its current form, or to make an example of any surgeon based on faulty data analysis,” he wrote in an email last week.

He criticized our use of hospital readmissions to identify instances when patients had suffered complications after surgery. “A readmission is not necessarily indicative of a complication, let alone a serious one,” he said.

The panel of doctors that helped design ProPublica’s methodology agreed on this point — which is why we only counted readmissions that these experts said were likely related to surgical complications.

Pronovost also said our analysis failed to recognize that some doctors are just more likely to readmit patients as a precautionary measure, even when there isn’t a serious complication.

But that doesn’t seem to explain the Medicare readmissions data for Han, the majority of whose patients typically stayed at least four days and had specific diagnoses of postsurgical complications. Medicare pays for patients to return briefly to the hospital under so-called observation status, but our analysis didn’t count these in tabulating complication rates.

Harvard School of Public Health professor Dr. Thomas Lee, who specializes in how to measure patient outcomes, was one of more than a dozen experts who evaluated ProPublica’s work. The differences between surgeons revealed by the analysis are sound — and important, he said.

“I think the methodology was rigorous and conservative,” Lee said. “I would be surprised if any experienced clinician challenged the basic finding, which is that there is real variation among surgeons.”

The proliferation of health care rankings by government agencies and a growing list of private organizations have fed the notion that patients can reliably decide where to get their care by choosing the institution or specialty first.

Yet Hopkins was one of many top-ranked hospitals where ProPublica found surgeons with problematic track records.

The orthopedic department of St. Joseph Hospital in Orange County, Calif., has been rated one of the top 50 in the country by U.S. News & World Report. Yet one of the surgeons, Dr. Gregory Carlson, had one of the highest complication rates for spinal fusions in the country, ProPublica found.

He said his results could reflect errors in the data submitted to Medicare. There is a “multitude of inaccurate and confusing information that is provided to state and federal organizations,” he said in an email.

The hospital’s chief executive, Steve Moreau, said St. Joseph rigorously tracks and compares the work of individual surgeons, and that it has led to lower complication rates in spinal procedures.

Rank and title do not guarantee results, ProPublica’s analysis shows.

At Chicago’s Weiss Memorial Hospital, the facility’s chairman of surgery, who is also the medical director of its center for orthopedics, had among the nation’s highest complication rates for knee replacement operations. Two dozen of the 219 Medicare patients he operated on between 2009 and 2013 subsequently exhibited complications.

In a statement, the hospital acknowledged it was aware of the complication rate compiled by the chairman, Dr. Henry Finn, “which reflects the complex cases Dr. Finn performs.” Finn added that he’s quick to readmit patients so that minor complications do not become more serious.

He said he was not surprised by the data.

“I’m treating aggressively, and that’s what I’d want done for myself,” he said. “It’s sad for me to hear this information. But I certainly hope it’s put in perspective.”

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