Healthcare DataGoals, Audiences, Difficulties

Timothy A. Denton, M.D., F.A.C.C.High Desert Heart Institute

Victorville, CA

California Medical Association8th Annual California

Healthcare Leadership Academy

• Datum [Pl. data] (L datum given, that which is given ) A thing given or granted; something known or assumed as fact, and made the basis of reasoning or calculation; an assumption or premiss from which inferences are drawn.

OED

Data Collection Efforts

• Scientific research

• Epidemiology

• Financial

• Government reporting

• Public reporting

Data:The Good the Bad and the Ugly

Cardiac Surgery Reporting

• Northern New England (1987)• New York (1989)• STS (1992)• Pennsylvania (1992)• VA NSQIP (1994) mort dec 27%• New Jersey (1994)• California (2001)

“…to give consumers information they can use in making informed choices…”

“…to encourage hospitals to take an in-depth look at their cardiac surgery programs, and make changes that can improve surgical outcomes…”

www.state.nj.us/health/hcsa/cabgs99/qna.htm

Cardiac Surgery Reporting

• Excess mortality Not believed, cases reviewed• Excess mortality in

high acuity patientsMI<6 hrs, emergency

• changed management of MI,NOT CABG

Dzubian et al. Ann Thorac Surg 1999;58:1871-1876

Data:The Good the Bad and the Ugly

Cardiac Surgery Reporting

• Cardiac Surgeon survey• 70% no change in practice• Gaming of risk factors• Refused high risk patients

because of reporting• “…denial of surgical treatment

to high risk patients.”

Burak et al. Ann Thorac Surg 1999;68:1195-1200

Medical Data Reporting

• America’s Best HospitalsUS News and World Reportwww.usnews.com

• Guide to HospitalsConsumer Checkbookwww.checkbook.org

• Hospital Report CardsHealth Grades, Inc.www.healthgrades.com

• JCAHOwww.jcaho.org

www.consumerreports.org

• CaliforniaCCMRP

• California(patient opinions)

• MarylandLOS, readmit, volume

• New JerseyCABG reporting

• New YorkCABG, PTCAPhysician-specific

• PennsylvaniaVolume, Mortality, LOS75 diagnostic groups

• TexasVolume, Mortality25 diagnostic groups

• VirginiaVolume, Mortality25 diagnostic groups

• South-Central WisconsinHip, Knee, cardiacEmployer alliance

HCFA Mortality Data

• Mid to late 1980’s• Administrative database• Risk adjustment from same dataset• Poor accuracy• Rarely used by consumers• 31% of hospitals used for internal purposes• Ultimately discontinued

JAMA. 1990;263:247-249JAMA. 2000;283:1866-1874.

Volume-Outcome Relationship

CCMRP 2001, Page 55

• Central Limit Theorem –The more you measure,the less you learn

• Rare events – 2 % outcomecharacteristics are verydifficult to stratify

More Problems

Data:The Good the Bad and the Ugly

Center for Medical Consumers

• “Patient safety crisis in New York State”

• “Report refutes medical lobby’s claimof doctor shortage in New York”

• “ ’Crisis’ in malpractice insurancemanufactured by organized medicine”

• “More is Better” (Surgical volumes)

www.medicalconsumers.org

Dear Dr. Denton,

Our pharmacy records indicate that your patient,George Washington, has been placed on amiodaroneand we don’t have evidence of a recent chest xraybased on billing records.

If you have not responded to this letter in two weeks,we will contact the patient directly to communicate ourconcerns to him.

Sincerely,

Your loving Health Insurance Company

An example letter

1. Short-term amiodarone

2. No indication for CxR

3. Patient admitted to hospital in interval

4. You are not licensed topractice medicine in California

5. You are interfering in theMD-patient relationship

6. State Board of Medical Examiners

An example response

A Different Ugly

• Patients want local care

• Patients believe in “their doctor”

• Patients don’t read the reports

• Patients can’t read the reportsin 60% of CABG cases

Data:The Good the Bad and the Ugly

The Solution

• What are the goals of healthcare?SurvivalQuality of life

• Are the data important?• Are the data accurate?• Are the data interpretable?• Are the data

reasonably collectable?• How will the data used?

First Principles

1. Performing CABG surgery

2. Decreasing CABG mortality from4.2% to 2.7%

3. Starting a statin on all CABGpatients

A Test

Which is more important in overall mortality?

Who is the audience?

• Patients

• Physicians

• Government

• Administration

• Payors

Types of Data

1. Mortality

2. Morbidity / Quality of Life

3. Process variables

4. Decision-making variables

First Principles

1. Patient care comes first

2. Variables that change system behavior

3. Variables collected with minimal intrusion

4. Reported to the correct audience

5. Physicians must lead