There are some 330 people alive and walking around in Pennsylvania these days who, statistically speaking, shouldn't be.
They should have died on the operating table, in the recovery room or in critical care, following their coronary artery bypass operation done between 1991 and 1993.
We don't know who they are or where they live, but we can say why they didn't die: Because Pennsylvania hospitals improved their cardiac care and physicians changed their practice protocols.
And at least part of the reason those improvements took place is the state published outcomes data for every hospital and physician that did coronary artery bypass surgery in each of those years.
The evidence is starting to pile up that hospitals and consumers alter their behavior based on the outcome and cost reports assembled by the Pennsylvania Health Care Cost Containment Council.
Created by the state Legislature in 1986, PHC4, as it's known, is authorized to collect, analyze and publish information about healthcare cost and quality.
"Our most popular report is the Consumer Guide to Coronary Artery Bypass Graft Surgery," said Joe Martin, spokesman for PHC4 (See graphic below). "We've done four annual ones, 1990 through 1993. The mortality rate for bypass procedures in Pennsylvania dropped 26%. It went from 3.9% to 2.9%."
If the 1990 mortality rate had continued for all four years, 330 more people would have died as a result of that procedure.
The agency also found that while the average hospital charge for a bypass operation grew, the rate of increase dropped to 4.6% in 1993 from 10% in 1990. And in 1995 hospital expenses rose only 1%, the lowest increase in six years.
"We're not saying that we are completely responsible for those statistics," Martin said. "There have been a lot of other factors going on. We think we have certainly played a role."
A study from Thomas Jefferson University Hospital in Philadelphia found that the state data are used in a multitude of ways by the public and healthcare purchasers to select providers.
Another paper recently prepared by four Pittsburgh-based researchers, John H. Evans, Yuhchang Hwang, Nandu Nagarajan and Karen Shastri, looked at how hospitals responded to the release of these reports. They found:
After the first year's disclosure of mortality and morbidity outcomes, hospitals with poorer mortality show the greatest improvement later.
Hospitals with better operating margins show greater improvements in mortality outcomes.
Poorly performing hospitals (measured by base-year mortality) lose market share in the period after disclosure, while better performing hospitals gain market share.
Outcomes tend to improve the most in those DRGs that bring in the most revenues for the hospital and in regions where there is more competition among hospitals.
It's much harder to measure and analyze outcomes data for morbidity than for mortality. Results were either not statistically significant or unclear.
Hospitals with poorer mortality rates tended not to reduce length of stay as much as hospitals with better mortality.
"Because long-term cost competitiveness is likely to require various efficiency improvements, including reductions in (length of stay)," the authors write, "the inability of poorly performing hospitals to simultaneously reduce (length of stay) and improve their outcomes may be significant." Disclosure of medical outcomes "has real economic consequences for hospitals."
Co-author Shastri, who teaches at Carnegie Mellon University, said it's surprising that "in an environment that is so cost-conscious, they are willing to sacrifice short-term profits to turn around their outcomes for the long term."
The effects of disclosure on a hospital's public perception can be dramatic. When the law first took effect, hospitals never dreamed they'd be hostage to so much publicity about their patient outcomes and charges. Newspapers in Pennsylvania delight in publishing the relative rankings of the hospitals in their community and asking hospital executives to justify a low score or a high price.
For that reason, and others, hospitals would rather not have to deal with the data reporting process, said Michael A. Young, chief executive officer of Lancaster Health Alliance. He cites three basic problems: errors in the algorithms used; the emphasis on hospital charges, which is now irrelevant; and "some aberrant severity adjustment factors that you just know in the pit of your stomach can't be right."
Young concedes PHC4 has made people stop and think about how they can better deliver care; the counterbalance is it costs his hospital $500,000 a year to collect the data.
Not only is the process expensive, agreed Sue Lawrence, a clinical resource manager at Lehigh Valley Hospital in
Allentown, the software supplied by the state is expensive and doesn't work properly.
Lehigh Valley has chosen to use the state data in its quality management program. Hospitals that haven't embraced this data for quality management resent having to spend so much money on it.
Across town at St. Luke's Hospital in Bethlehem, James Cowan, M.D., said his hospital has improved its case documentation in response to the published reports. Getting the severity adjustments right not only gives a more accurate reading to PHC4, "it allows our internal quality improvement activities to be much more data driven than they used to be," Cowan said.
In Caesarean sections and myocardial infarctions, St. Luke's has seen real changes in practice protocols. Its C-section rate dropped to 17% from 25% in response to the PHC4 reports.
"First of all, in anticipation of publication of the data, there's a lot of apprehension that you're going to be an outlier," Cowan said. "Even the fact that the study's going to be done produces some changes."
In myocardial infarction, the hospital used a HCFA study of best practices in combination with the state data to guide internal quality improvement. Now it makes sure that people get aspirin when they first come to the hospital, and that they're put on the appropriate drugs before they leave. "We're shooting for 100% in all those categories of care," Cowan said.
Ernest Sessa, executive director of PHC4, says hospitals may grumble, but the results of 10 years of work are clear: "If you create a competitive healthcare environment and give people information on healthcare cost and quality, they'll buy quality care and it will end up costing less."