Hannan's Report Leads to Improved Cardiac Care

All 54 people who had an emergency heart bypass operation at St. Peterís hospital in Albany in 1993 survived ó a dramatic improvement over the previous year, when one of every four died.

This information, contained in a state Health Department report, was generated by University researcher Edward Hannan, recently named chair of the Department of Health Policy and Management in the School of Public Health.

"Thereís a lot of evidence that disseminating this kind of information to hospitals and surgeons has helped them to improve their quality of care," said Hannan. "These methods are now being used by other states and with other types of health care."

In 1991, St. Peterís had a poorer record than most of the other 30 hospitals performing heart bypass surgery in New York State. St. Peterís investigated, and today, after Hannanís results clued the hospital in to the need to look at their own performance record, a patientís chances of survival following cardiac surgery at St. Peterís are among the best in the state.

Each year beginning in 1991 the Health Department has calculated the mortality rates of hospitals and surgeons who perform heart bypass surgery in New York state and reported the information to the public. A statistical formula, developed using information from thousands of cases, is used to estimate the likelihood of each patientís chances of survival. The formula takes into account the par-ticular circumstances of each individual patient. Each surgeon and each hospital cardiac unit is measured against how closely their experience with patients matches the predicted outcomes.

Although the purpose of the project was to help cardiac units improve the quality of care and thereby lower patient mortality, hospitals and physicians have been concerned that reaction might actually result in worse patient care. For example, they worried that a physician might avoid seriously ill patients more likely to die following cardiac surgery because deaths would negatively affect his or her record.

In a recent issue of The New England Journal of Medicine, however, New York Health Commissioner Barbara DuBuono, her predecessor, Mark Chassin, and Hannan report that the mortality rate following heart bypass surgery has been almost cut in half in New York since 1989, when the Health Department began to collect data for this project. In 1992, roughly 25 of every 1,000 patients died following surgery, compared to 42 deaths per 1,000 five years earlier.

While improved surgical techniques account for some of the reduced mortality, there is evidence that hospitals and surgeons have used the departmentís reports to improve patient outcomes during this period.

For example, one of the earliest findings was that surgeons who performed relatively few operations had worse records than those who operated frequently. Be-tween 1989 and 1992, 27 low-volume surgeons withdrew from cardiac surgery ó surgeons whose average mortality rate during that five-year period was more than three times the statewide average. Other programs have been able to refer patients to surgeons whose records showed above-average performance in treating cardiac patients with specific medical complications.

Physicians and hospitals questioned the accuracy of the data and whether the formula works, given the extenuating circumstances of severely ill patients. In reply, the authors point out that independent audits requested by the Health Department have predicted the same chances of survival as the original data.

Moreover, the formula has shown its accuracy in pre-dicting the risk of death for patients at various stages of illness. A comparison of actual outcomes with predicted outcomes for more than 40,000 patients from 1990 through 1992 shows that the model is as accurate for patients most likely to die as it is for those least likely.

More than 16,690 adults underwent cardiac bypass operations in New York in 1993. A cardiac bypass operation provides auxiliary blood flow to the heart in patients whose heart arteries are blocked.

The success of this method in reducing mortality from heart bypass operations attests to the usefulness of the approach in improving care in other areas of medical treatment. The Health Department has already begun to use the same approach to improve trauma care and delivery room care.

The ratings of New York hospitals and physicians are available by contacting the Public Affairs Office of the New York State Health Department, Corning Tower Building, Empire State Plaza, Albany, NY 12237.

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