If you’re shopping for a car, it’s easy to find information on gas mileage, repair rate, and other factors of interest to consumers. Moreover, it’s possible to compare models in order to find which one is most likely to meet your needs. Can you do the same with heart surgeons?
Yes, you can, but it’s not easy. Although some of the information consumers want is available on government, insurance company, and commercial websites, a Harvard study found that the data are not always presented in ways that are easy to understand and interpret correctly.
How public surveys fall short
“Several public agencies have tried to respond to consumer demand for information about which doctors and hospitals are better than others, but it has turned out to be more complex than it appears,” says Dr. Karen Donelan, the senior survey scientist from the Mongan Institute of Health Policy at Harvard-associated Massachusetts General Hospital and lead author of the study.
The study was initiated when Massachusetts decided to make information on complications and death rates from coronary artery bypass grafting (CABG) procedures available to the public. Dr. Lawrence H. Cohn, a distinguished heart surgeon at Brigham and Women’s Hospital and a professor of surgery at Harvard Medical School, was invited to help determine what information should be presented and how.
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“The public should have the opportunity to know who’s the best. Our state is one of a handful that documents every morbidity [complication] and mortality [death] associated with every CABG. The issue was how to make this accessible to the consumer,” Dr. Cohn says.
Perceptions make a difference
For data to be useful, they must be presented in a way that can be understood and easily interpreted. Dr. Donelan and a team from Partners Healthcare created a survey with data presented in four different formats, including the one used in Massachusetts. Each format contained information on three to five fictitious surgeons and included the number of CABGs performed, patient operative deaths, observed patient mortality, expected patient mortality, and risk-adjusted mortality.
The researchers discovered that the ability to correctly interpret which surgeon was best varied between 16% and 66%, depending on the format.
“Some displays were more understandable than others, but the ones the respondents said they preferred were not necessarily the ones they interpreted accurately,” says Dr. Donelan. “Some people liked numbers in a table. Some liked graphs with colors and bars. Others were better with proportions, rates, and measurements,” she says.
In addition, the survey revealed that most people desire information on others’ experiences with care, including their perception of their surgeon’s interpersonal skills, in addition to objective measurements.
Issues with terminology
It was also apparent that most people did not understand the terminology used in the graphs, particularly the important concept of “risk-adjusted mortality.” Instead, they focused on number of deaths. Because the concept of risk adjustment is so critical to distinguishing the role of major medical centers, this greatly concerned the Harvard researchers.
“Tertiary care hospitals care for very sick people who are referred because they may be too complicated for a community hospital to handle. Sicker patients are at higher risk for poor surgical outcomes. If you only look at mortality rates that do not adjust for these risks, you may miss this fact,” says Dr. Donelan.
Dr. Andrew Eisenhauer, a cardiologist at Harvard-affiliated Brigham and Women’s Hospital and co-author of the survey study, says the impact of this misunderstanding has backfired.
“It is said that public reporting saves lives, because the overall death rate following heart surgery has decreased over time. But the hospitals where deaths occur are treating the sickest patients. These people have a greater chance of being helped, but because they are so ill, a higher percentage of them may die. Even when this risk is accounted for, some skilled surgeons have developed an aversion to operating on the sickest patients due to concerns about public reporting. Therefore, desperately ill patients may be left out.”
No simple answer
Because people want to make informed choices, the American Society of Thoracic Surgeons has made its members’ statistics available. You can find them at www.health.harvard.edu/CABG. States that gather such data are working on the best ways to present it.
“Public reporting is good in theory, but difficult in concept. It’s like saying, ‘What’s the best car?’ There are many opinions and many factors to consider when deciding what’s best for you,” says Dr. Eisenhauer.