AnesthesiaWeb - Lit Reviews- Health-care Report Cards and Implications for Anesthesia

August 1998

Health-care Report Cards and Implications for Anesthesia
Swamidoss CP, Brull SJ, Watrous G, Barash PG. Anesthesiology. 1998;88:809-819.
No abstract available

Swamidoss et al start out their paper with a quote from TS Eliot: "Where is the knowledge we have lost in information?" I liked it immediately.

What is a health care report card? This term refers to any effort to compile "grades" on how well you are doing in meeting some goal—e.g. patient outcomes, adherence to standards of care, costs. Report cards compare individual providers to studies which simply report incidences. For example, a study may find that 10% of patients have MIs. A report card lists your percentage of patients with MI and compares it to the mean of the group to whom you are being compared.

The authors nicely trace the history of report cards, noting that they were first advocated in the early 1900s. The author of that early treatise was Ernest Codman, who envisioned health report cards as a way for patients to choose physicians, and hospitals to credential those MDs who wish to practice on their premises. One hundred years later, we are on the verge of another Jules Verne reality check.

Using health care report cards is very controversial because the ability to quantify patient morbidity is FAR from foolproof, and comparisons can only be valid when this fact is taken into account. Despite this, report cards are becoming increasingly common. This article notes that the Department of Health and Human Service's General Accounting Office studied this very issue, and concurred with the above observation. Risk adjustment was not very good, and even if it were, releasing information to a public not schooled in risk adjustment could be extremely misleading. Furthermore, with no indication that outcomes were affected by reporting this data, the cost-effectiveness of this approach cannot be quantified.

Physicians are not the only group subjected to report cards. For example, the National Committee for Quality Assurance (NCQA) issues report cards on managed care organizations on behalf of employers and patients. They use standardized measures, and participation is purely voluntary.

The most recent widespread implementation of report cards of interest to the anesthesia community is the JCAHO initiative that defined 8 anesthesia indicators to be compared among hospitals (see Table). Currently voluntary, these indicators may become mandatory for comparison of all accredited hospitals in the near future. With very little being done in anesthesia right now, the authors lobby for three report cards, which would contain information directed at the three groups needing information: patients, health care purchasers, and regulatory agencies. In the paper they include an example of what information they consider appropriate, and describe the Yale Department of Anesthesiology approach. The last part of the paper provides report card examples based upon the system used at Yale.

Table. JCAHO Anesthesia Indicators*

Numerator	Indicator
AN-1	Patient developing a CNS complication during or within 2 postprocedure days of procedures involving anesthesia administration, subcategorized by ASA-PS class, patient age, and CNS versus non-CNS related procedures
AN-2	Patients developing a peripheral neurologic deficit during or within 2 postprocedure days of procedures involving anesthesia administration
AN-3	Patients developing an acute myocardial infarction during or within 2 postprocedure days of procedures involving anesthesia administration, subcategorized by ASA-PS class, patient age, and cardiac versus noncardiac procedures
AN-4	Patients with a cardiac arrest during or within 1 postprocedure day of procedures involving anesthesia administration, subcategorized by ASA-PS class, patient age, and cardiac versus noncardiac procedures
AN-5	Patients with unplanned respiratory arrest during or within 1 postprocedure day of procedures involving anesthesia administration
AN-6	Death of patients during or within 2 postprocedure days of procedures involving anesthesia administration, subcategorized by ASA-PS class and patient age
AN-7	Unplanned admission of patients to the hospital within 2 postprocedure days of procedures involving anesthesia administration
AN-8	Unplanned admission of patients to an intensive care unit within 2 postprocedure days of procedures involving anesthesia administration and with ICU stay >1 day.

*The denominator for indicators 1-6 and 8 is the number of inpatients undergoing procedures that usually require the use of anesthesia, defined by an inclusive list of ICD-9-CM codes. No denominator information was collected for indicator 7.

In the old days, a bad grade on your report card meant staying home Saturday night. Now it may mean no work, or mandatory re-training. A very sobering thought. Although we must proceed carefully, as the authors suggest, we must lead the way and find a reasonable process to grade ourselves before someone does it for us.

Return to the Current Literature Review Front Page

Numerator

Indicator

AN-1

Patient developing a CNS complication during or within 2 postprocedure days of procedures involving anesthesia administration, subcategorized by ASA-PS class, patient age, and CNS versus non-CNS related procedures

AN-2

Patients developing a peripheral neurologic deficit during or within 2 postprocedure days of procedures involving anesthesia administration

AN-3

Patients developing an acute myocardial infarction during or within 2 postprocedure days of procedures involving anesthesia administration, subcategorized by ASA-PS class, patient age, and cardiac versus noncardiac procedures

AN-4

Patients with a cardiac arrest during or within 1 postprocedure day of procedures involving anesthesia administration, subcategorized by ASA-PS class, patient age, and cardiac versus noncardiac procedures

AN-5

Patients with unplanned respiratory arrest during or within 1 postprocedure day of procedures involving anesthesia administration

AN-6

Death of patients during or within 2 postprocedure days of procedures involving anesthesia administration, subcategorized by ASA-PS class and patient age

AN-7

Unplanned admission of patients to the hospital within 2 postprocedure days of procedures involving anesthesia administration

AN-8

Unplanned admission of patients to an intensive care unit within 2 postprocedure days of procedures involving anesthesia administration and with ICU stay >1 day.