Heart doctors at risk of bad rep
Public reports on bypass deaths may deter surgeons from taking tough cases.
Michael Koumjian, a heart surgeon for nearly three decades, said he considered treating the sickest patients a badge of honor. The San Diego doctor was frequently called upon to operate on those who had multiple illnesses or who’d undergone CPR before arriving at the hospital.
Recently, however, Koumjian received some unwelcome recognition: He was identified in a public database of California heart surgeons as one of seven with a higher-than-average death rate for patients who underwent a common bypass procedure.
“If you are willing to give people a shot and their only chance is surgery, then you are going to have more deaths and be criticized,” said Koumjian, whose riskadjusted death rate was 7.5 per hundred surgeries in 2014-15. “The surgeons that worry about their stats just
don’t take those cases.”
Now, Koumjian said he is reconsidering taking such complicated cases because he can’t afford to continue being labeled a “bad surgeon.”
California is one of a handful of states — including New York, Pennsylvania and New Jersey — that publicly reports surgeons’ names and risk-adjusted death rates on a procedure known as the “isolated coronary artery bypass graft.”
The practice is controversial: Proponents argue that transparency improves quality and informs consumers. Critics say it deters surgeons from accepting complex cases and can unfairly tarnish doctors’ records.
“This is a hotly debated issue,” said Ralph Brindis, a cardiologist and professor at UC San Francisco who chairs the advisory panel for the state report. “But to me, the pros of public reporting outweigh the negatives. I think consumers deserve to have a right to that information.”
Prompted by a state law, the Office of Statewide Health Planning and Development began issuing the reports in 2003 and produces them every two years. Outcomes from the bypass procedure had long been used as one of several measures of hospital quality. But that marked the first time physician names were attached — and the bypass is still the only procedure for which such physician-specific reports are released publicly in California.
California’s law was sponsored by consumer advocates, who argued that publicly listing the names of outlier surgeons in New York had appeared to bring about a significant drop in death rates from the bypass procedure.
State officials say it has worked here as well: The rate declined from 2.91 to 1.97 deaths per 100 surgeries from 2003 to 2014.
“Providing the results back to the surgeons, facilities and the public overall results in higher quality performance for everybody,” said Holly Hoegh, manager of the clinical data unit at the state health planning and development office.
Since the state began issuing the reports, the number of surgeons with significantly higher death rates than the state average has ranged between six and 12, and none has made the list twice. The most recent report, released in May, is based on surgeries performed in 2013 and 2014.
In this year’s report, the seven surgeons with aboveaverage death rates — out of 271 surgeons listed — include several veterans in the field. Among them were Daniel Pellegrini, chief of inpatient quality at Kaiser Permanente San Francisco and John M. Robertson, director of thoracic and cardiovascular surgery at Providence Saint John’s Health Center in Santa Monica.
Most defended their records, arguing that some of the deaths shouldn’t have been counted or that the death rates didn’t represent the totality of their careers.
“For the lion’s share of my career, my numbers were good and I’m very proud of them,” Pellegrini said. “I don’t think this is reflective of my work overall. I do think that’s reflective that I was willing to take on tough cases.”
During the two years covered in the report, Pellegrini performed 69 surgeries and four patients died. That brought his risk-adjusted rate to 11.48 deaths per 100, above the state average of 2.13 per 100 in that period.
Pellegrini said he supports public reporting, but he argues the calculations don’t fully take the varying complexity of the cases into account and that a couple of bad outcomes can skew the rates.
Robertson said in a written statement that he had three very “complex and challenging” cases involving patients who came to the hospital with “extraordinary complications and additional unrelated conditions.”
They were among five deaths out of 71 patients during the reporting period, giving him an adjusted rate of 9.75 per 100 surgeries.
“While I appreciate independent oversight, it’s important for consumers to realize that two years of data do not illustrate overall results,” Robertson said. “Every single patient is different.”
The rates are calculated based on a nationally recognized method that includes deaths occurring during hospitalization, regardless of how long the stay, or anytime within 30 days after the surgery, regardless of the venue. All licensed hospitals must report the data to the state.
State officials said that providing surgeons’ names can help consumers make choices about who they