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Feasibility of Report Cards for Measuring Anesthesiologist Quality for Cardiac Surgery
Laurent G Glance1, Edward L Hannan, Lee A Fleisher
1From the *Department of Anesthesiology, University of Rochester School of Medicine, Rochester, New York; †Department of Health Policy, Management and Behavior, School of Public Health, University at Albany, Albany, New York; ‡Department of Anesthesiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania; §U.S. Anesthesia Partners; ‖Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York; and ¶RAND Health, Boston, Massachusetts.
Insights
Pay-for-performance (P4P) metrics for anesthesiologists are not feasible due to minimal outcome variability. Anesthesiologists showed modest impact on cardiac surgery outcomes, with no outliers identified, unlike surgeons.
Area of Science:
- Anesthesiology
- Cardiac Surgery Outcomes
- Health Services Research
Background:
- The Merit-Based Incentive Payment System mandates pay-for-performance (P4P) for physicians, including anesthesiologists.
- Currently, no National Quality Forum-endorsed risk-adjusted outcome metrics exist for anesthesiologist P4P.
- This study addresses the need for quality metrics in anesthesiology for P4P implementation.
Purpose of the Study:
- To examine the variation in patient outcomes attributable to anesthesiologists in cardiac surgery.
- To assess the feasibility of using mortality or major complications as P4P metrics for anesthesiologists.
- To compare the contribution of anesthesiologists to patient outcomes with that of hospitals and surgeons.
Main Methods:
- Retrospective observational study of 55,436 cardiac surgery patients (2009-2012).
- Hierarchical logistic regression to analyze in-hospital mortality or major complications.
- Controlled for patient demographics, disease severity, comorbidities, and hospital quality.
Main Results:
- Anesthesiologist performance variation was statistically significant but modest (ICC=0.0051, MOR=1.13).
- No anesthesiologists were identified as high- or low-performance outliers.
- Hospitals (ICC=0.029, MOR=1.35) and surgeons (ICC=0.018, MOR=1.26) showed greater outcome variability, with 12 surgeon outliers identified.
Conclusions:
- Anesthesiologists' contribution to cardiac surgical outcome variability is significantly less than surgeons'.
- The limited variability and lack of outliers suggest P4P metrics based on death or major complications may not be feasible for cardiac anesthesiologists.
- Further research may be needed to develop appropriate quality metrics for anesthesiology P4P.
Background:
In creating the Merit-Based Incentive Payment System, Congress has mandated pay-for-performance (P4P) for all physicians, including anesthesiologists. There are currently no National Quality Forum-endorsed risk-adjusted outcome metrics for anesthesiologists to use as the basis for P4P.
Methods:
Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 55,436 patients undergoing cardiac surgery between 2009 and 2012. Hierarchical logistic regression modeling was used to examine the variation in in-hospital mortality or major complications (Q-wave myocardial infarction, renal failure, stroke, and respiratory failure) among anesthesiologists, controlling for patient demographics, severity of disease, comorbidities, and hospital quality.
Results:
Although the variation in performance among anesthesiologists was statistically significant (P = 0.025), none of the anesthesiologists in the sample was classified as a high- or low-performance outliers. The contribution of anesthesiologists to outcomes represented 0.51% of the overall variability in patient outcomes (intraclass correlation coefficient [ICC] = 0.0051; 95% confidence interval [CI], 0.002-0.014), whereas the contribution of hospitals to patient outcomes was 2.90% (ICC = 0.029; 95% CI, 0.017-0.050). The anesthesiologist median odds ratio (MOR) was 1.13 (95% CI, 1.08-1.24), suggesting that the variation between anesthesiologist was modest, whereas the hospital MOR was 1.35 (95% CI, 1.25-1.48). In a separate analysis, the contribution of surgeons to overall outcomes represented 1.76% of the overall variability in patient outcomes (ICC = 0.018, 95% CI, 0.010-0.031), and the surgeon MOR was 1.26 (95% CI, 1.19-1.37). Twelve of the surgeons were identified as performance outliers.
Conclusions:
The impact of anesthesiologists on the total variability in cardiac surgical outcomes was probably about one-fourth as large as the surgeons' contribution. None of the anesthesiologists caring for cardiac surgical patients in New York State over a 3+ year period were identified as performance outliers. The use of a performance metric based on death or major complications for P4P may not be feasible for cardiac anesthesiologists.
