Are High-Quality Cardiac Surgeons Less Likely to Operate on High-Risk Patients Compared to Low-Quality Surgeons? Evidence from New York State

Patient race, ethnicity, and socioeconomic status (SES) are known to be important determinants of access and quality in the American health care system in general (Agency for Healthcare Research and Quality 2005) and for coronary artery bypass graft (CABG) care in particular (Mukamel, Weimer, and Mushlin 2006; Mukamel et al. 2004). Until recently, the question of whether severely ill patients also encounter barriers to health care received very little attention. In the new era of “scorecard medicine” (Topol and Califf 1994), there is concern that public reporting of health care quality may lead some physicians to avoid sicker patients in order to improve or “protect” their performance rating (Werner, Asch, and Polsky 2005). While striving to decrease the disparities for traditional vulnerable populations such as nonwhite and low-income patients, it is possible that a potentially more vulnerable patient population of high-risk patients will be increasingly denied access to high-quality care because of the perception that caring for them may threaten a physician's or hospital's quality ranking. Physician and hospital profiling is becoming increasingly pervasive (Marshall et al. 2000), driven by the widespread perception of quality deficits in the health care system (Schuster, McGlynn, and Brook 1998; Institute of Medicine 2000; McGlynn et al. 2003) and the demand for accountability and reform (Institute of Medicine 2001). Report cards are designed to allow patients and third-party payers to make informed choices, and to provide physicians and hospitals with benchmarking information to use for quality improvement. Report cards may also have unintended consequences. In New York State (NYS), which is widely believed to produce one of the most credible quality measures for CABG surgery, over 60 percent of cardiothoracic surgeons surveyed report that they refused to operate on high-risk patients on at least one occasion (Burack et al. 1999) and 83 percent of interventional cardiologists indicated that they were more reluctant to treat high-risk patients as a result of public reporting of physician outcomes (Narins et al. 2005). Although the evidence of the impact of public reporting on access to care is mixed (Omoigui et al. 1996; Peterson et al. 1998), recent work suggests that in the most severely ill patients with acute myocardial infarctions (AMI), performance profiling led surgeons to preferentially operate on lower-risk patients (Dranove et al. 2003). This resulted in higher rates of heart failure and recurrent AMI, and possibly higher mortality rates in patients admitted with AMI in states with public report cards compared with states without public reporting (Dranove et al. 2003). We examined whether high-risk cardiac surgical patients are less likely to receive care from high-quality surgeons compared with lower-risk patients. This analysis was performed using patient-level data from the NYS CABG Surgery Reporting System (CSRS) database, which contains clinical data on mortality and preoperative risk factors for all patients undergoing isolated CABG surgery in NYS (Hannan et al. 1994). We hypothesized that high-risk patients would be less likely to receive CABG surgery from high-quality surgeons and more likely to be treated by low-quality surgeons. We note that due to limitations of these data (which do not include information about distance, zip code or sociodemographics), we are not estimating a choice model. Furthermore, our analysis cannot ascertain whether the sorting of patients and surgeons is due to patient or surgeon choice. Thus, this study answers the question of whether there is a sorting of patients (by risk) and surgeons (by quality), but does not address the question of what processes and mechanisms lead to this sorting.