CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Zoltan G. Turi, MD*
* Robert Wood Johnson Medical School, Cooper Vascular Center, Cooper University Hospital, One Cooper Plaza, Camden, New Jersey 08103 (Email: Turi-Zoltan{at}cooperhealth.edu).
Dr. Smith’s kind categorization of my editorial (1) as generally both "lucid and well-reasoned" is tempered by what appears to be lack of awareness of New York State’s report card for his own institution. "Two hospitals (Columbia Presbyterian-NYP and Westchester Medical Center) had risk-adjusted mortality rates that were significantly higher than the statewide rate" was clearly stated in the New York State Department of Health report of April 2004, Adult Cardiac Surgery in New York State (2), based on the data (2001) available at the time of President Clinton’s bypass surgery. Thus, Dr. Smith’s testimonial that "Risk-adjusted CABG mortality at Columbia Presbyterian has never, ever been ‘significantly’ higher than the statewide average" and "I reiterate, Columbia Presbyterian was not one of these statistical outliers, and has never been one of them" is inaccurate. The risk-adjusted mortality rate (RAMR) for Columbia Presbyterian in that report was 3.93 (95% confidence interval [CI] 2.33 to 6.21). The statewide RAMR was 2.18, placing Columbia’s CI range entirely above the statewide mean, the definition for "significantly higher" explicitly stated in the report. Thus, despite his invitation to the reader, namely "let us agree ... that roughly half the hospitals ... have risk-adjusted CABG mortality that is ‘higher’ ... and about half the hospitals are lower," only two hospitals had CIs that put them entirely above the mean.
Mr. Altman’s New York Times article stated the following (3): "The hospital where former President Bill Clinton awaits bypass surgery has the highest death rate for the operation in New York State, according to the state’s Health Department. While the death rate is quite low—fewer than 4% of all bypass operations—it is still nearly double the average for hospitals in the state that perform bypasses ... . Columbia Presbyterian and Westchester Medical Center were the only two hospitals in the state that had risk-adjusted death rates that were significantly higher than the statewide rate." My only reference was to the last sentence, included almost verbatim (discreetly omitting hospital names). I am puzzled why Dr. Smith states the citation was inaccurate.
As to the question of taste, "heroism" was neither stated nor implied, and Dr. Smith’s use of that word is hyperbole. "Courage" was the term used; it did not originate with me, and it was a quote rather than a self-congratulatory description of a rather routine procedure. Neither "heroism" nor "courage" is implied by the actions of 62% of surgeons in New York State who admitted not performing cardiac surgery because of fear of public reporting (4) or by the opinion of 83% of interventional cardiologists that high-risk patients are similarly denied percutaneous coronary intervention (PCI) (5). As to the ad hominem attack on "dragging an individual patient into print" (the patient was neither dragged nor identified), public policy ultimately has important effects on individual patients. Anecdotal examples are an appropriate editorial tool to highlight the human consequences of risk-averse heart surgeons and interventional cardiologists. "A single death is a tragedy, a million deaths is a statistic" (Joseph Stalin’s comment to Winston Churchill at the Potsdam Conference) argues for looking beyond arcane discussions of risk-adjustment techniques to this policy’s effect on individuals.
Figure 2 in the study by Moscucci et al. (6) shows that the hospital in New York with the highest percentage of cardiogenic-shock patients still does fewer such cases than the hospital with the lowest rate in the Michigan consortium. Given the 41% reduction in mortality suggested by the SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK (SHOCK) trial registry (7), the fact that PCI for cardiogenic shock is performed one-quarter as often in New York State as in Michigan suggests that this is a statistic with considerable tragedy attached.
Further, as to the question of taste, I was careful not to mention Columbia Presbyterian or Westchester Medical Center by name anywhere in my editorial. I do not believe these numbers reflect quality of care at either hospital. Dr. Smith’s letter misses one of my major points: individuals sophisticated enough to understand the limitations of public reporting recognize that the risk-adjusted mortality rate is so flawed as to be potentially useless. At the same time, as my editorial (1) maintained, the net effect of public reporting does significant harm to the public, both because patients may be misled in their decision making, and because physicians, as I believe is illustrated by Dr. Smith’s letter, are driven to great lengths by discomfort with their own or their institution’s reported outcomes.
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1. Turi ZG. The big chill. The deleterious effects of public reporting on access to health care for the sickest of patients J Am Coll Cardiol 2005;45:1766-1768.[Free Full Text]2. New York State Department of Health Adult Cardiac Surgery in New York State, 1999–2001. 2004Available at: http://www.health.state.ny.us/nysdoh/heart/pdf/1999-2001_cabg.pdf. Accessed April.[Free Full Text] 3. Altman LK. Clinton surgery puts attention on death rate. New York Times, Sept. 6, 2004, Sect. A:1.. 4. Burack JH, Impellizzeri P, Homel P, et al. Public reporting of surgical mortalitya survey of New York State cardiothoracic surgeons. Ann Thorac Surg 1999;68:1195-1200.[Abstract/Free Full Text] 5. Narins CR, Dozier AM, Ling FS, et al. The influence of public reporting of outcome data on medical decision making by physicians Arch Intern Med 2005;165:83-87.[Abstract/Free Full Text] 6. Moscucci M, Share D, Smith D, et al. Relationship between operator volume and adverse outcome in contemporary percutaneous coronary intervention practicean analysis of a quality-controlled multicenter percutaneous coronary intervention clinical database. J Am Coll Cardiol 2005;46:625-632.[Abstract/Free Full Text] 7. Webb JG, Sanborn TA, Sleeper LA, et al. Percutaneous coronary intervention for cardiogenic shock in the SHOCK Trial Registry Am Heart J 2001;141:964-970.[CrossRef][Web of Science][Medline]
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