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Information about ongoing health services research and public health projects
| Screening surveillance for possibly adverse effects of outcomes reporting
(Archived Project) |
|
|---|---|
| Investigator (PI): | Baine, William B |
| Performing Organization (PO): |
(Current): Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement (CEPI) / (301) 427-1600 |
| Supporting Agency (SA): | Agency for Healthcare Research and Quality (AHRQ) |
| Initial Year: | 2012 |
| Final Year: | 2012 |
| Record Source/Award ID: | AHRQ/IM12384 |
| Award Type: | Intramural |
| Abstract: | Government and private entities increasingly require physicians and hospitals to divulge information on the outcomes of their procedures.(1) Outcome variables may include data on survival or complications, such as nosocomial infections.(2) The consequences of reporting unfavorable results may include loss of reputation and compensation. Requirements for reporting have not generally awaited development of methods to assure comparability of reporting sensitivity and specificity among the organizations and individuals whose performance is under scrutiny.(3-9) The possibility that publicizing data that was formerly restricted to internal review for quality assurance may entail conflicts of interest in patient care has also not been exhaustively evaluated. Many clinical encounters are routine and hardly require more than accurate documentation. At the other end of the spectrum, if the patient's condition is so grave that intervention would be futile, the appropriate emphasis is upon humanitarian and moral support. However, clinical diagnosis and therapy often entail assuming risk. Informed consent and participation of the patient in choosing among plausible options are most important when both the disease and the proposed interventions may be hazardous. Traditional medical ethics emphasize the primacy of the patient's interest. Equipoise is understood to focus on the balance of risks and benefits to the patient. Requiring the hospital or physician to report adverse events to outsiders introduces another axis to the analysis of benefits and harms. It is not axiomatic that patients will always be best served by decisions that will minimize the risk of reportable adverse outcomes. If prudence becomes timidity, the patient may not be offered an option that would probably yield the best outcome but at some greater risk of adding to the toll of reported misadventures. That is, equipoise might shift from the patient's utilities to the doctor's. The risk of foreclosing preferred but hazardous options may be greatest at the borders of acceptable risk, when the clinician might already have doubts about the prospects for success. For example, if a surgeon already considers old age an important variable in predicting the risk of an operation, then aged patients may be particularly likely to find themselves being passed over for a procedure. Similarly, if a surgeon is skeptical, even if only unconsciously, of the reliability of members of minority groups to adhere to postoperative instructions, needed but risky options may not be thoroughly considered in the care of some racial and ethnic groups. Analogous considerations may apply to women. An important point about such a decision, though, is that it would be very hard to detect. How do you count the number of times a particular operation was not performed? Comparing age-adjusted procedure rates in men and women or blacks and whites may reveal differences, but substantial differences might be legitimate if sex and race are closely tied to the incidence of the underlying pathology. Preliminary work on coronary artery stenting was consistent with a hypothesis whereby, as they gained experience with the new technique, cardiologists not only increased the number of procedures that they performed, but also over time extended the procedure to older patients at presumably higher risk of complications (Baine WB, Helmchen L. Unpublished data). The possibility then presents itself that under circumstances that encourage a more risk-averse practice style, the secular trend might proceed in the opposite direction, with retreat from the oldest patients along the age-practice frontier. To detect and discuss trends involving the extension of procedures to the oldest potential beneficiaries, as well as possible retrenchment in favor of clients with greater physiologic reserve, a summary measure would be useful. Conventional age-adjusted procedure rates would assure comparability from year to year; however changing patterns at the periphery of the age-practice frontier would not necessarily call attention to themselves. A cantilever beam presents an interesting metaphor and model.(10) If the origin be taken as the point at which the beam thrusts outward past the vertical support of the wall, then each additional patient may be represented by a weight placed upon the beam, and the distance of the weight from the origin can increase as some function of the age of the patient. To make the system even more sensitive to the oldest patients, loading can be envisioned not merely as the number of cases at a given age, but as the age-specific attack rate. It is likely that among the very oldest aged patients rates will be unstable, so some multi-year groupings will be necessary. Alternatively, it may be preferable to censor the process at some advanced age. With a real cantilever beam, the maximum moment--the force tending to rotate the beam--depends upon whether the load on the beam is uniformly distributed (wl2/2, where w <=> the load in pounds per linear foot and l <=>length of the beam in inches) or instead concentrated at the free end (Pl, where the concentrated load is in pounds-feet). Since we seek a summary measure of the moment for a series of age-specific annual procedure rates, the moment will be taken as the sum of the age-specific maximum moments from 64 through 95 years. Other relevant details include the point on the metaphorical beam at which to locate the youngest aged Medicare patients (aged 64 years on December 31 of the year before they become eligible and in the denominator file for that year) or, stating the same issue in another way, what age to assign to the point of the beam at which it emerges from underlying support. Another consideration in the model is how to weight one year's difference in ages between two patients. Should there be a linear increase with age? The actual age-specific risk of death in this population rises exponentially, at least until the very oldest of the old. A complete unknown is the way surgeons incorporate the patient's age into the preoperative risk assessment--linearly, exponentially, or in some incremental saltatory fashion. Coronary artery bypass grafting,(11) total hip replacement, and total knee replacement(12) provide three common and expensive operations that should be considered for early evaluation. The null hypothesis is that introduction of reporting systems does not perturb established secular trends in the age-practice frontier. Procedures in which reporting was instituted at the level of individual states should be particularly informative. (1) Nicholas LH, Osborne NH, Birkmeyer JD, Dimick JB. Hospital process compliance and surgical outcomes in Medicare beneficiaries. Arch Surg. 2010;145:999-1004. (2) McKibben L, Horan TC, Tokars JI, Fowler G, Cardo DM, Pearson ML, Brennan PJ; Healthcare Infection Control Practices Advisory Committee. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 2005;26:580-7. (3) Sherman ER, Heydon KH, St John KH, Teszner E, Rettig SL, Alexander SK, Zaoutis TZ, Coffin SE. Administrative data fail to accurately identify cases of healthcare-associated infection. Infect Control Hosp Epidemiol. 2006;27:332-7. (4) Humphreys H, Cunney R. Performance indicators and the public reporting of healthcare-associated infection rates. Clin Microbiol Infect. 2008;14:892-4. (5) Mazor KM, Dodd KS, Kunches L. Communicating hospital infection data to the public: a study of consumer responses and preferences. Am J Med Qual. 2009;24:108-15. (6) Wright SB, Ostrowsky B, Fishman N, Deloney VM, Mermel L, Perl TM. Expanding roles of healthcare epidemiology and infection control in spite of limited resources and compensation. Infect Control Hosp Epidemiol. 2010;31:127-32. (7) Bell S, Benneyan J, Best A, Birnbaum D, Borycki EM, Gallagher TH, Goeschel C, Jarvis B, Kushniruk AW, Mazor KM, Pronovost P, Sheps S. Mandatory public reporting: build it and who will come? Stud Health Technol Inform. 2011;164:346-52. (8) Birnbaum D, Zarate R, Marfin A. SIR, you've led me astray! Infect Control Hosp Epidemiol. 2011;32:276-82. (9) Mayer J, Greene T, Howell J, Ying J, Rubin MA, Trick WE, Samore MH; for the CDC Prevention Epicenters Program. Agreement in classifying bloodstream infections among multiple reviewers conducting surveillance. Clin Infect Dis. 2012; (10) O'Hara SE, Ballast DK. Architecture Exam Review. Volume I: Structural Topics. "Beams and columns." 6th ed. 4-1 - 4-12. Belmont, CA. Professional Publications, Inc. 2005 (11) Masud F, Vykoukal D. Preventing healthcare-associated infections in cardiac surgical patients as a hallmark of excellence. Methodist Debakey Cardiovasc J. 2011;7:48-50. (12) Marjoua Y, Butler CA, Bozic KJ. Public reporting of cost and quality information in orthopaedics. Clin Orthop Relat Res. 2012;470:1017-26. |
| MeSH Terms: |
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| Country: | United States |
| State: | Maryland |
| Zip Code: | 20850 |
| UI: | 20131351 |
| Project Status: | Archived |
