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A Novel Approach to Evaluating Cardiac Surgery Providers: An Alternative to the RAMR
Christine Pitocco1, Thomas R Sexton1
1College of Business, Stony Brook University, Stony Brook, New York, USA.
Insights
A new method using upper and lower tail probabilities (UTP/LTP) of the binomial distribution offers an alternative to the Risk Adjusted Mortality Rate (RAMR) for evaluating healthcare provider performance in cardiac surgery.
Area of Science:
- Biostatistics
- Health Services Research
- Surgical Outcomes
Background:
- The Risk Adjusted Mortality Rate (RAMR) is used by New York State to identify underperforming cardiac surgeons and hospitals.
- Four significant concerns have been identified with the current RAMR methodology.
Purpose of the Study:
- To propose and evaluate an alternative methodology for assessing provider performance.
- To address the identified limitations of the RAMR in cardiac surgery outcomes analysis.
Main Methods:
- Utilized upper and lower tail probabilities (UTP/LTP) of the binomial distribution.
- Applied the UTP/LTP methodology to New York State cardiac surgery data from 2011-2013.
Main Results:
- The UTP/LTP approach demonstrated agreement with RAMR in classifying all surgeons and hospitals.
- The UTP/LTP method avoids strict categorization, allowing for identification of marginal providers.
Conclusions:
- The UTP/LTP methodology effectively addresses the four identified concerns with RAMR.
- This approach aligns with statistical theory, handles case volume appropriately, and does not require confidence intervals.
Objective:
We propose an alternative to the Risk Adjusted Mortality Rate (RAMR), about which we identify four serious concerns. We apply our method to cardiac surgery.
Design:
We present a methodology that uses the upper and lower tail probabilities (UTP/LTP) of the binomial distribution to screen for poor/high performing providers.
Study Setting:
The New York State Department of Health (NYS DOH) publicly releases data on all cardiac surgery patients in the state. We download cardiac surgery data from the NYS DOH website for the years 2011 through 2013. The state's objective is to identify poorly performing hospitals and surgeons and thereby reduce deaths. NYS employs the RAMR.
Results:
The UTP/LTP approach agrees with the RAMR in its classification of all 132 surgeons and all 40 hospitals. However, performance is a continuous construct and strict categorization can lead to failure to identify marginal providers.
Conclusions:
Our methodology addresses all four concerns regarding the RAMR. The UTP/LTP approach avoids inappropriate hypothesis testing and is consistent with standard statistical theory and practice in its approach to case volume. It does not require confidence intervals and it applies to all providers regardless of case volume.
