JACC: Should cards base surgery referrals on report cards?
“There has been growing international interest, particularly in developed countries, in providing greater transparency in healthcare,” David L. Brown, MD, Stony Brook University in Stony Brook, N.Y., et al wrote. “Public reporting of clinical outcomes data is one response to calls for increasing transparency in healthcare.”
Brown et al, in a viewpoint published in the June 19/26 issue of the Journal of the American College of Cardiology, asked whether cardiologists' ethical principles should obligate them to discuss outcomes data with patients as they refer them to cardiac surgery. They recommended that cardiologists use these report cards during referrals, despite the fact that the benefits of making these data publicly available remain unknown.
“We believe that strong grounds for this ethical obligation exist, whether or not patients themselves make use of such report cards in evaluating and making decisions about individual cardiac surgeons,” the authors wrote.
They highlighted three ethical arguments for cardiac surgeon report cards:
- Surgeon report cards enable patients to make better decisions about surgery;
- Report cards help surgeons meet their professional accountability obligations by demonstrating to the community that surgical care is being provided to requisite levels of quality; and
- Report cards are believed to improve the safety and quality of patient care overall.
“Thus, the provision of surgeon performance information to patients who see this as material to their decision making about surgery is required by widely accepted conceptions of the ethical doctrine of informed consent,” the authors wrote.
Brown et al said that while these surgeon report cards are widespread, they are not being used when cardiologists are referring patients into surgery.
“We argue that cardiologists have an ethical obligation to use cardiac surgeon report cards to refer patients to the best available cardiac surgeon,” they wrote. “Because the welfare of a patient will be maximally promoted by referring that patient to the best available surgeon, cardiologists have a responsibility to refer their patients to the surgeon with the best risk-adjusted outcomes.”
However, two editorialists felt differently. “How could one possibly argue with the notion that cardiologists should refer their patients to the 'best' available surgeon with the 'lowest mortality rates'?" wrote David M. Shahian, MD, of Massachusetts General Hospital, and Sharon-Lise T. Normand, PhD, of Harvard School of Public Health, both in Boston, in an accompanying commentary.
While Shahian and Normand said that they support transparency and accountability, they expressed concern with Brown et al’s proposal, saying that more objective, evidence-based approaches should be used.
“It presupposes an extremely restrictive view of what it means to be the 'best,' it makes paternalistic judgments about what should be most important to patients, and its expectations regarding the capabilities of provider profiling are unrealistic,” the editorialists wrote.
Shahian and Normand questioned what Brown et al meant by “lowest risk-adjusted mortality rate” and questioned the fact that Brown et al defined “best” surgeon on the basis of lowest risk-adjusted mortality.
Brown et al acknowledged that their viewpoint was controversial. They wrote that there likely will be skepticism about the accuracy of these types of report cards, concerns about conflicting loyalties and questions about responsibility.
Brown et al wrote that they agreed these data should be accurate, but they believed it would not be appropriate to withhold the information from patients. The authors suggested that the best approach is having the cardiologist refer the patient to the cardiac surgeon and then share any concerns about the accuracy of these data with the patients.
"Many cardiologists may prefer to refer patients to cardiac surgeons operating at their own institutions, even when they are aware that there are better cardiac surgeons available operating elsewhere,” Brown et al wrote. However, the authors said that it is the cardiologists’ duty to protect the welfare of the patient and refer him or her to the surgeon with the best outcomes, no matter the institution they practice at.
Cardiologists “should advise patients of the best available surgeon and of the waiting time required for that surgeon, as well as advising patients of the best of those available surgeons who can be booked more expeditiously,” they summed.
While the editorialists agreed with Brown et al that there is an ethical obligation to assess performance, they disagreed that cardiologists should refer patients “only to the best cardiac surgeon as defined by having the lowest risk-adjusted mortality rate.”
Instead, Shahian and Normand suggested that referrals be based on patient history, clinical presentation, procedures, goals and experience and capabilities with available surgeons. “This approach is most likely to yield the 'best' outcome from all relevant perspectives,” the editorialists summed.