CARDIAC CARE: A Review Of New York’s Bypass Scorecards

      A study in the current Journal of the American College of Cardiology concludes that New York's bypass surgery "scorecards" for individual doctors and hospitals have had a positive impact on bypass care in the state. Critics have charged that the scorecards could limit access to cardiac care, as physicians concerned about protecting their "cardiovascular scorecards" would refuse to operate on high-risk patients. But researchers from the Duke University Medical Center found no evidence that access to bypass surgery declined after the scorecards were introduced in 1989 and confirmed that outcomes from the surgeries "improved markedly" since the scorecard program began.

Improved Access
      The researchers used national Medicare data to test whether or not the scorecards were limiting high-risk patients' access to bypass surgery and forcing them to go out-of-state for care. They examined "trends in the percentages of N.Y. residents aged 65 years or older receiving out-of-state" versus in-state surgery between 1987 and 1992 -- the period before and after the inception of New York's provider profiling program. The researchers found that "the percentage of N.Y. residents receiving bypass out-of-state actually declined" from 12.5% to 11.3%. Moreover, the study found that elderly N.Y. heart attack patients were "significantly" more likely to receive bypass surgery after the scorecard program began.

Better Outcomes
      To test whether or not patient outcomes improved, the researchers used the same set of national Medicare data to "compar[e] trends in surgical outcomes in N.Y. Medicare patients with those for the rest of the nation." They found that "mortality rates following bypass declined by 33% in New York Medicare patients compared with a 19% decline nationwide." In addition, New York "had the lowest risk-adjusted bypass mortality rate of any state in 1992." The researchers noted that "procedural outcomes in N.Y. improved significantly faster than the national average." The authors said this trend is "profound" given that it occurred immediately after the scorecard program began and "during a period when national mortality averages declined only slightly."

Limitations and Conclusions
      The researchers cautioned that their conclusions are only relevant for "patients aged 65 or older and may not reflect care patterns or outcomes in younger patients." Additionally, the "results only reflect care through the end of 1992 and N.Y. surgeons may have altered their practice patterns since then." Despite these limitations, the authors concluded, "These data support N.Y.'s provider profiling program as a potential means of improving patient outcomes while maintaining access to care" (Peterson et al, October 1998 issue).