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Why Choosing the Right Surgeon Matters

SurgeryIn a January report called “Shining a Light,” the National Patient Safety Foundation defined four levels of  transparency in health care: between clinicians and patients; between clinicians within an organization; between multiple health care organizations; and between providers and the public.

The report endorsed all four, calling transparency the most effective, inexpensive and underutilized tool for improving the quality of care.

In the few instances where such an approach has been tried, there’s powerful evidence that it works.

After New York started publishing individual surgeons’ mortality rates for heart bypass procedures, the state’s overall mortality rates for bypass surgery dropped dramatically, studies showed. Some surgeons with poor results stopped operating or left New York. Hospitals upgraded their protocols to ensure best practices.

Yet overall, the U.S. health care system still provides little transparency about the varying performance of doctors.

In part, this is because doctors have resisted it. In 1979, the American Medical Association sued to bar the disclosure of how much individual physicians were paid by Medicare. The group won a court ruling that stood until 2013 and made it virtually impossible to publish doctor-specific data.

Even now, the government mostly leaves it to others to provide the public with quality-of-care data about doctors. CMS’ Physician Compare website, which is supposed to help patients choose providers, gives information on doctors’ specialties, location and gender — but nothing on how their patients fare.

A few hospitals have introduced programs that suggest the transforming effect greater transparency could have were it embraced more broadly.

On a wintry day in January, officials at Beaumont Hospital, Royal Oak, outside Detroit, convened a predawn meeting of the surgeons, residents, nurses and physician assistants who make up the orthopedics staff.

Beaumont comprehensively tracks complication rates and other quality measures by doctor. Surgeons in the orthopedic department had grown accustomed to receiving their own results and anonymized data for their colleagues.

But at this gathering, department leaders unveiled each surgeon’s performance metrics for the previous year on a giant screen at the front of the room. Dr. Lige Kaplan, one of the surgeons, compared it to being at school and having your report card shared with all your classmates.

There was undeniable power in putting the information out there, where everyone could see it.

“When you get that grade, if you don’t like that grade or think you can do better,” Kaplan said, “you either study harder or go to the teacher and ask, ‘What can I do better?’”

Several factors led Beaumont, which has more than 1,000 beds and is well known for orthopedics, to start tracking and sharing doctor-specific data.

The hospital had hired Dr. Samuel Flanders to be the health system’s chief quality and safety officer. Flanders considered tracking doctors’ results one component of a systemic, data-driven quality improvement program.

Hospital leaders saw Medicare had begun introducing payment incentives and penalties to reduce patient harm and knew this would continue. Also, the hospital became part of a Blue Cross Blue Shield of Michigan initiative that pays facilities to compile and share surgical quality data.

Mainly, though, the orthopedics department’s results were not as good as the hospital wanted them to be. ProPublica’s analysis shows that some surgeons at Beaumont had high complication rates for the procedures we examined in Medicare. Beaumont declined to supply its internal quality data, but said its numbers paralleled ProPublica’s.

Once Beaumont’s orthopedics department started tracking data by doctor, certain statistics jumped out immediately.

For example, too many patients were receiving blood transfusions. This can put patients at higher risk for complications.

Tracking data also showed that some of Beaumont’s orthopedic surgeons had unusually high infection rates. Guidelines say patients getting knee replacements should receive antibiotics an hour or two before surgery to fend off such complications. Beaumont found that surgeons were ordering antibiotics haphazardly, some so late that patients still hadn’t received the drugs when they were about to be wheeled into the operating room.

The hospital changed its practices to fix these issues and more, using the data as a road map.

Collectively, the changes brought about a dramatic improvement in surgeons’ results, hospital officials said. Indeed, ProPublica’s data shows that between 2010 and 2013, the hospital cut its complication rate on knee replacements in half.

The meeting in January tapped into doctors’ competitive side.

“It gives the individuals a little extra incentive to look better,” said Dr. James Verner, one of the surgeons there that day. “We’re all competitive in our own way.”

Kaplan, one of the better-performing surgeons at Beaumont in ProPublica’s analysis, said two colleagues approached him afterward to ask how they could improve their transfusion rates.

Beaumont’s orthopedics department has continued to meet quarterly, putting each surgeon’s stats up on the big screen. At the April meeting, the group was eager to see whether there had been improvements, said Dr. Jeffrey Fischgrund, the department’s chairman and a spine surgeon.

“At the January meeting, it was, ‘Why are we doing this?’ ” Fischgrund said. “At the April meeting, it was, ‘Did we make a difference? Is this worth it?’ ”

Sure enough, the group found out there had been a drastic reduction in transfusion rates compared with the previous three months. “You can influence physician behavior through the open discussion of data,” Fischgrund said.

Despite these gains, some of Beaumont’s surgeons said they remain opposed to making individual performance data public.

Verner said patients might blame surgeons for complications that weren’t their fault and surgeons might avoid higher-risk cases that could damage their complication rates.

“I’d rather work to improve someone than publicly shame them,” Fischgrund said. “It’s not that you want to get rid of the outliers, you want to shift the whole curve.”

Some patient safety advocates say it’s not enough for hospitals to share doctors’ track records internally yet withhold this information from patients.

“If you leave it up to altruism of hospitals, you end up with what we have now — just a few that use meaningful data to improve quality,” said Dr. Marty Makary, a surgeon and professor at the Johns Hopkins University School of Medicine. “Broader transparency, if done fairly and accurately, can drive this improvement with greater force.”

By Marshall Allen and Olga Pierce

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Marshall Allen is a ProPublica reporter covering health care and patient safety issues. Olga Pierce is the Deputy Data Editor at ProPublica.

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