To follow up on Monday’s post, I take a few quotations from Rachel Werner and David Asch’s paper (“The Unintended Consequences“) in the March 9, 2005 edition of JAMA. First, I look at the unintended consequence of coronary artery bypass graft (CABG) report cards in a number of U.S. states:
In Pennsylvania, which also introduced CABG report cards, 63% of cardiac surgeons admit to being reluctant to operate on high-risk patients, and 59% of cardiologists report having increased difficulty in finding a surgeon for high-risk patients with coronary artery disease since the release of report cards. New York had a similar experience after the release of report cards, reporting that 67% of cardiac surgeons refused to treat at least 1 patient in the preceding year who was perceived to be high risk.
The authors worry that quality report cards may move the physicians emphasis away from providing guidance and quality medical care and towards achieving the target rates. The authors also cite a work by Walter et al. (JAMA 2004), which examines colorectal cancer screening compliance rates. Walter and co-author’s work finds that
“…among patients who did not undergo CRC screening, 47% had declined screening, 12% failed to complete or keep appointments for screening, and in 31% of patients, testing was not medically indicated or the patient had high levels of comorbid illnesses. While the hospital in question may have failed to meet the VA’s target rate of CRC screening, 90% of unscreened patients may have been appropriately unscreened.”
I repeat: while pay-for-performance or quality rating systems have the potential to increase quality throughout the medical system, these performance metrics, must be very carefully designed to take into account many of the issues addressed above.