Analysis : Quality Medical Data Is Better Than Ever, Hard to Obtain

A highly regarded report on 13 hospitals in this month’s Annals of Internal Medicine concluded that the intensive-care unit rated best saved nearly three times as many lives as the one ranked last. But by not disclosing which hospitals fared well and which poorly, the study underscored a little-noticed paradox in the health care business:

More and better data than ever is being gathered to assess the quality of medical care, but such information is rarely available to consumers at all, much less in a useful way.

Thus, despite Wednesday’s unprecedented release by the federal government of the names of hundreds of hospitals with abnormal death rates for Medicare patients, consumer groups are continuing to push for more meaningful data.

“This is an important crack in the secrecy of this information,” said Dr. Sidney Wolfe of the Washington-based Public Citizen Health Research Group, a leading advocate of health data disclosure.

The information released this week was developed by the federal Health Care Financing Administration to help Medicare watchdog groups, called peer review organizations, target hospitals that require closer scrutiny.

The data, including overall death rates as well as mortality rates for nine specific surgical and medical conditions, is based on statistical analyses of the billing information on millions of Medicare patients treated in 1984 at hospitals throughout the country.

The “raw” computer printouts were not meant to be disclosed, but the HCFA changed its mind after the existence of the information became public. Further data releases are not currently planned.

It is very difficult to define quality medical care and to devise methods to measure it. Serious efforts to look at this issue on a broad scale began with the passage of Medicare in 1965.

Before then, such assessments were done sporadically by individual hospitals and involved mainly autopsies and reviews of tissues removed during surgery to learn the results of operations and whether they had been necessary.

But Medicare required hospitals to establish review committees to look carefully at the records of patients receiving medical and surgical care paid for by that program. Such reviews, intended as feedback for a hospital’s medical staff, were supposed to improve the care of private as well as Medicare patients.

In 1975, another federal law required the establishment of professional standards review organizations, or PSROs, outside the hospitals.

But none of the information gathered by these review groups was made available to the public, despite the efforts of consumer groups. Some information gathered separately by states was publicized.

More recently, the PSROs were replaced by the statewide peer review organizations, who contract with the federal government to oversee Medicare. Under regulations that took effect last spring, these groups must make available to the public, upon request, extensive information on Medicare patients.

The regulations state that hospital-specific data, on items such as mortality, number of discharges and infection rates, can be released, as long as individual physicians and patients are not identified. Hospitals are given 30 days’ advance notice to comment. Their comments also are released.

To date, very little of this information has been made public. “People have been jibed all over by peer review organizations when they have tried to get things,” said the Health Research Group’s Wolfe.

In California, for instance, California Medical Review Inc., of San Francisco, announced that it would release in February standard reports comparing health care for Medicare patients at hospitals throughout the state for the first half of 1985.

But after the hospital comments were received, the release was canceled because of “problems” with the reports and “confidential” information contained in some of the comments, according to a spokeswoman. No new release date has been set.

The Health Research Group is preparing a guide on how to obtain information from peer review organizations, understand it and use it to improve health care.

As an example of what can be done, Wolfe said, he intends to write letters to the boards of trustees of all 33 hospitals in the nation identified Wednesday in the federal data as having abnormally high death rates for coronary artery bypass surgeries. The 24 hospitals that did fewer than 100 such surgeries on Medicare patients in 1984 each had death rates of more than 14%, contrasted with predicted rates of about 5%.

“These hospitals should stop doing the operations,” Wolfe said. “The malpractice implications are extraordinary in a positive sort of way.”

It is unclear whether and when more and better information than that released Wednesday will be made public. But, in the meantime, as the report in the Annals of Internal Medicine illustrates, some studies may lead to improved medical care even when they don’t identify by name the hospitals with problems.

‘Atmosphere of Distrust’

The intensive care unit study, which included Stanford University Medical Center, found that one hospital had 58% more ICU deaths than expected. The major factors that contributed to the high death rate, it turned out, were poor communications, nursing staff shortages and “an atmosphere of distrust” between doctors and nurses, according to the study’s director, Dr. William A. Knaus of George Washington University.

He said the report eliminated differences other than the quality of medical care, so that the intensive care units could be compared. It thus avoided many of the problems with using the Medicare data released by the federal government to make such comparisons.

Knaus was able to do the study only because the hospitals had volunteered to participate. The hospitals were guaranteed that their rank would not be disclosed. None of the hospitals challenged the findings.

“Confidentiality was important for this study because it was a pilot study,” Knaus explained.

He felt that his obligation was to visit the hospital that ranked last and report his findings. While initially “no one felt responsible,” Knaus said, the leadership of the hospital eventually changed and improvements in intensive care were made, partly in response to the study.