Health care report cards may increase racial/ethnic disparities in bypass operations

Medical "report cards" intended to improve the quality of health care may sometimes reduce it for racial and ethnic minorities, according to a report in a special disparities themed issue of Circulation: Journal of the American Heart Association.

Several states began publishing coronary artery bypass graft (CABG) report cards in the 1990s in an effort to improve the quality of CABG care in those states. Report cards are a state-level initiative, typically administered by a state's Department of Health.

These report cards report risk-adjusted death rates for surgeons and hospitals that perform CABG surgery. They are designed to improve quality by enabling patients to select high-quality providers and giving providers benchmarks and incentives to improve the quality of care they provide. Recent evidence suggests that after CABG report cards were released, surgeons began to avoid patients they perceived as being high-risk.

"In our study we found that health care report cards, as they are currently implemented, may have the opposite effect of how they were intended to work," said Rachel M. Werner, M.D., the study's first author and an assistant professor of medicine at the University of Pennsylvania School of Medicine in Philadelphia and staff physician at the Philadelphia Veterans Affairs Medical Center. "One implication of our study is that report cards work in ways that are more complicated than we assumed, and some physicians may respond to them inappropriately."

The researchers reviewed physician-specific report card data in New York. New Jersey and Pennsylvania also publish physician-specific CABG report cards. All three states also issue hospital-specific report cards. California has hospital-specific report cards only. Among the states studied (New York plus 12 controls) only New York released CABG report cards during the study period from 1988-95. Control states were defined by data from the Healthcare Cost and Utilization Project (HCUP-3), a data set that includes hospital discharge information nation-wide. Researchers only used data from the 12 states in HCUP-3 that reported patient race, which were California, Colorado, Connecticut, Florida, Iowa, Kansas, Massachusetts, Maryland, Missouri, New Jersey, South Carolina, and Wisconsin.

Werner and her colleagues compared hospital discharge data on 928,551 acute heart attack patients including 310,412 patients in New York. Blacks and Hispanics accounted for 13.7 percent of the New York patients and 10 percent of patients in the comparison states. New York released its first surgeon-specific CABG report card in December 1991. Researchers found that after the report card was released, the gap in CABG surgery in New York between whites versus blacks and Hispanics widened significantly.

Among the New York patients, blacks and Hispanics were less likely to receive CABG than white patients after the report card was released. Prior to the report card, CABG rates were 3.6 percent for whites, 2.9 percent for Hispanics and 0.9 percent for blacks. After the report card's release, even though CABG rates increased overall, the difference in CABG use between white vs. Hispanic patients and white vs. black patients increased (8 percent of white patients vs. 4.8 percent of Hispanic patients and 3 percent of black patients). In the comparison states, the disparity between the races in the same time frame was not statistically significant.

The researchers also note that despite the relatively lower use of CABG among racial and ethnic minorities after the report cards were released in New York, there was no increase in angioplasty procedures – often a substitute procedure for CABG – in these groups.

These results suggest that some surgeons responded to CABG report cards by excluding some patients from CABG surgery on the basis of race and ethnicity, Werner said. "It's possible that physicians believe that minority patients are less likely to comply with treatment, more likely to refuse treatment, and delay seeking care for additional health problems."

"Although this increase in disparities appears to be transient, it took nine years after report cards were established for the differences in CABG use in blacks, Hispanics, and whites to return to where they were before the first report card's release," Werner said. Studies have indicated that report cards are generally beneficial. But there is still concern that some physicians might select lower risk patients to improve their public ratings.

"The finding that report cards increased racial and ethic disparities in CABG should not be taken as a reason to abandon quality-improvement. Instead, it suggests that report cards may need to be improved to increase their impact on patients' physician selection, and reduce physicians' incentive to select patients on the basis of their perceived risk," Werner said. Co-authors are David A. Asch, M.D., and Daniel Polsky, Ph.D.