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Comment by mturmon | Hacker News Reader

They link to a heart surgery compilation by the Society of Thoracic Surgeons (http://www.sts.org/quality-research-patient-safety/sts-publi...) which is fun to explore.

In metro LA, the top-tier hospitals (Cedars-Sinai, UCLA) have noticeably better outcomes than regular hospitals. The difference is like 98.7% of patients not dying versus 97.9% in a valve replacement ("AVR"). Flip it around and it's 1.3% versus 2.1% -- definitely noticeable.

OTOH, UCSF (presumably top-tier, SF residents correct me if I'm mistaken) has 2.3% chance of dying. Maybe it's not a top-tier facility for AVR?

And further, a small midwestern hospital in Hays, KS (pop. 21000) has a 3.6% chance of death. That's huge next to Cedars-Sinai at 1.3%!

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These ratings are not great because they incentivize doctors not to take more complex cases. They claim to be risk-adjusted, but in reality you cannot adjust for all possible risk factors. Lots of things in medicine are very unique. There's very little that's more complex than human disease.

As a referral center for other referral centers, additionally UCSF will be getting some of the most complicated cases in the world.

I agree that numbers can be gamed, and it's possible that private hospitals might be particularly motivated to do so. Indeed, probably these numbers don't make much sense for anyone outside a small medical community of insiders to assess.

I'm not holding a torch for Cedars, but they are of similar stature for referrals AFAIK (not directly on-point, but indicative: https://www.cedars-sinai.edu/About-Us/News/News-Releases-201...).

That's true, they are a high profile center in this field.

In a previous life I worked for cardiac surgeons - one of them was on a board for the State of Florida to research outcomes and how to publish them without affecting which cases are taken.

In the case of one example where NY started publishing outcomes the difficult cases switched to the Cleveland Clinic. The outcomes appearred to increase in NY and decrease at the Cleveland Clinic, but risk adjusted rates didn’t actually change for NY hospitals that transferred cases or for the Cleveland Clinic.

This is absolutely something that happens and Cardiac Surgeons are all scientists to some degree. The results and risk adjustments are very well documented and they can determine them with a fair degree of accuracy. I’m not aware of the info for this particular case, but if they did risk adjust (the patient) it right - there are still a lot of other factors that determine quality of care (speed of delivery of service) and quantity of surgerys performed (if you don’t perform enough surgeries per year your quality suffers). Incidently, this is true for surgical staff (nurses) as well. If the surgeon travels to numerous to hospitals… the hospitals with the most surgeries performed will have better outcomes (after risk adjustment for them doing higher risk surgeries).

It's not that some surgeries are being shifted from one center to another, its that no one at all will do them, generally to the detriment of the patient.

Someone will do them. There is a business model for surgeons who only take the sickest patients. Sure, in that case your numbers are worse, but that's the way you market yourself.

> These ratings are not great because they incentivize doctors not to take more complex cases.

This reminds me of a scene in the recent Dr. Strange movie where the main character -- a neurosurgeon -- turns down a case because it had a high risk of failure and he didn't want to tarnish his perfect record.

> They claim to be risk-adjusted, but in reality you cannot adjust for all possible risk factors. Lots of things in medicine are very unique. There's very little that's more complex than human disease.

Isn't it better to approach the problem by improving how we do these risk assessments so that the risk-adjusted ratings are fair, as opposed to leaving patients in the dark about where to get the best care?

It's hard to just "improve the risk adjustments." The statistics aren't there.

I agree patients shouldn't be left in the dark. The most important thing is getting the best care. There isn't an easy solution.

However, I think the existing solution hurts patients (and I have seen these risk assessments first-hand numerous times).

It reminds me of a relative who couldn't find a surgeon for his problem, because the first 2 thought he was a risky patient. Then the 3rd charged more.

And thinking about it, I realized how many projects I jumped in while others jumped out because, you know, they were risky in not succeeding...

You seem to be saying that a hospital that doesn't want to take complex cases can more accurately adjust for risk factors than the people doing the study mentioned in the article. Is that right?

Not the GP but I generally assume that a patient's actual doctors know more about that patient's physical body and how it will impact a procedure than some academics who are classifying/"coding" thousands of case files.

Surgeons talk about a "look test" that refers to that certain something not captured by objective risk measures. A patient who doesn't look too bad on paper may look in person like they might not survive a haircut, let alone a valve replacement.

The database can store both objective and subjective risk measures. If there is good evidence that a 'look test' can improve risk assessment, lets get the referring doctor to perform a look test and store the result in the database. In that way the hospital will not have an edge over the risk-adjustment model used in the study.

Edit: Many patients are already assessed by performance status [1]

[1] https://en.wikipedia.org/wiki/Performance_status

You also have to consider that the Hays, KS hospital, being a much smaller hospital, has a much smaller number of cases. The confidence interval around that is definitely larger as a result. Not sure how much larger, but likely enough to make the difference statistically insignificant (town pop is 21k, heart surgery # is likely very low).

Put another way, a single death out of a small population of patients will have a larger impact on the statistics.

Another data point: 30-day mortality rates for high-risk acute heart patients are lower during the dates of national cardiology meetings, i.e. when the top doctors are away.

http://jamanetwork.com/journals/jamainternalmedicine/fullart...

> Flip it around and it's 1.3% versus 2.1% -- definitely noticeable.

Flip it back around and it is a 0.9% reduction in survival rates. ;-)

I'm going to guess that hospitals aren't exactly the biggest factor influencing outcomes...

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