Science / Medicine : COMMENTARY : Hospitals Turn Critical Eye to Required Self-Criticism

In a little-noticed article in the British Medical Journal last year, a highly respected family physician from a small Welsh coal mining village analyzed 500 consecutive deaths in his practice over a 21-year period. His goals were to determine which deaths might have been preventable and, in so doing, to help himself and other physicians take better care of their patients.

In the article, Dr. Julian Tudor Hart acknowledged that his own errors, including “poor organization and follow-up,” might have contributed to 45 of the deaths. In four cases, he took himself to task for “incomprehensible clinical blindness” that tragically delayed a correct diagnosis.

Such public self-criticism would be considered heretical in the United States, where physicians and hospital administrators are not only reluctant to acknowledge their fallibility but are also concerned about potential malpractice litigation.

Moreover, Hart’s example highlights a key paradox of the public release of hospital-specific death-rate data in the United States. The medical community is still so uncomfortable with the fact that it is being done at all, that the goals of the data releases--informing consumers and improving medical care--are often obscured.

Mortality data “is sort of the AIDS of the hospital industry,” said Dr. Stephen F. Jencks of the U.S. Health Care Financing Administration.

Jencks spoke last month at a conference on mortality data organized by the Chicago-based Joint Commission on Accreditation of Healthcare Organizations. The meeting brought together physicians, hospital and regulatory agency officials, consumer groups and journalists to discuss the impact of the increased availability of the statistics.

Under federal regulations that took effect in April, 1985, the statewide peer review organizations that contract with the federal government to oversee Medicare must make available to the public, upon request, extensive statistical information on hospital performance in caring for the elderly and disabled.

In addition, similar non-confidential data on nearly all hospitalized patients is available in some states, such as California and Maryland. Neither the federal nor state data includes information on individual physician performance.

The raw data consists of a seemingly endless series of numbers on reels of computer tapes. Unless the data is decoded and analyzed, the numbers are meaningless. The commonly used death rate statistics, for example, indicate the percentage of patients with a particular medical condition or surgery who either die in the hospital or within a 30-day period after hospital admission.

Over the last two years, there have been two data releases by the Health Care Financing Administration, as well as releases by California Medical Review, the state peer review organization. Some news organizations, including The Times and Knight-Ridder newspapers, have published their own analyses of some of the data.

Another Health Care Financing Administration data release is planned for December. California Medical Review, however, has no plans to repeat its widely publicized April, 1987, data release, according to a spokeswoman.

“The key question now is whether these disclosures will be done usefully and well,” said Thomas J. Moore, a Washington journalist who spoke at the conference and co-authored a series of articles on heart bypass surgery death rates that were published in Knight-Ridder newspapers in the fall of 1986.

For many diagnoses, such as heart failure, pneumonia and stroke, physicians and health policy experts are uncertain whether variations in hospital mortality rates reflect differences in quality of care. They may reflect other factors, such as variations in the severity of the patients’ illness or the inability of the health care system to prevent the natural biological process of death.

But for some common operations, such as coronary artery bypass and carotid endarterectomy, most experts agree that death rate statistics are medically meaningful.

The death rate data can help hospitals target areas needing in-depth evaluation to pinpoint poor quality care and can help identify high quality services, according to Dr. James S. Roberts, a joint commission senior vice president. The data can also serve as a starting point for patients in asking questions of their physicians and contribute to better public understanding of health care.

For these goals to be accomplished, however, many experts believe that the medical community will have to become less defensive about the data and more open to frank discussion of what it does well and what it could do better.

One way to encourage this trend would be for more institutions, such as medical schools, teaching hospitals and the joint commission, to produce such analyses and to make them public on a regular basis.

According to Moore, “The news media will perform the analysis itself only on rare occasions and mainly if other institutions with more expertise fail to meet their responsibility.”