Flap Over Number of Cardiac Surgeries : Medical Journal Recants Its Scripps Allegation
Scripps Memorial Hospital in La Jolla gets its day in print today, as the New England Journal of Medicine corrects an allegation of unnecessary cardiac surgeries that has had Scripps in an uproar since the mistake’s publication June 9.
“I regret the embarrassment caused the Scripps Hospital by my editorial, which cited erroneous information derived from data the hospital submitted to the California Office of Statewide Health Planning and Development,” says an apology in today’s issue of the journal, written by health researcher Dr. Philip Caper.
A protest letter from Scripps doctors also was included in the magazine, as well as a formal correction notice and an apology from the editor-in-chief of the magazine.
Unhappiness Remains
But the high emotions generated by the controversy remain much in evidence at Scripps.
“I’m not happy with it. I think we were hurt, and I think that the effort to ameliorate our hurt was inadequate,” said Dr. David B. Carmichael, Scripps’ cardiovascular director, of the journal’s attempt to resolve the matter.
Carmichael complained that the correction was too small and that Caper’s apology letter avoided key issues of his own responsibility.
The controversy started shortly after the New England Journal published an editorial by Caper, head of the Codman Research Group in Hanover, N.H.
Editorial Statement
In discussing overused medical services, the editorial contended that “a resident of La Jolla, Calif., is more than three times as likely to undergo a coronary-artery bypass operation (which will probably be performed at Scripps Hospital) as a resident of Palo Alto.”
Scripps doctors took that not only as a statement that they were doing unnecessary operations but also as an implication that the surgeries are not as competently done at Scripps as at Stanford University Medical Center in Palo Alto.
Scripps doctors checked, and discovered that the hospital’s bypass surgery numbers appeared high relative to the population within its service area because Scripps contracts to do such surgeries for Kaiser Permanente. These patients come from throughout San Diego County, but, in reports to the state, the Kaiser patients were given the Kaiser billing ZIP code as their residential code.
Thus, there appeared to be too many surgeries in relation to the population in the hospital’s service area. When Caper looked at the state data, he did not notice the anomaly.
‘No Difference’
“When the data are corrected, there is no difference between La Jolla and the state average,” the letter to the journal from three Scripps doctors says.
It is signed by John K. Cherry, chief of staff; Frederic C. Shean, a senior physician at the hospital; and Carmichael.
Scripps remains at odds with Caper and the journal over who was responsible for the error.
“The original error, after all, was made when officials at your hospital provided data to the California health facilities data base. Dr. Caper quoted those data correctly, I believe,” wrote Dr. Arnold S. Relman, editor-in-chief, in a letter to Scripps on Aug. 10.
Cherry responded with a letter protesting the implication of “a continuing perception” that the hospital contributed to the error.
Derek Pogson, spokesman for the state office that collected the data, said hospitals are supposed to report it based on patients’ residential ZIP codes, not billing ZIP codes.
Carmichael said the hospital provided both billing and residential addresses to a computer firm that it pays to collate Scripps’ data to give to the state. So, if there was an error in the ZIP codes, it was the contracting firm’s, not the hospital’s, he said.
The New England Journal’s correction and apologies by Caper and Relman avoided assigning blame specifically to the hospital.
“This unfortunate affair might have been avoided had any of the parties concerned checked the data, but there isn’t much point now in trying to assign blame,” Relman wrote.
In a telephone interview, Caper said he regrets not having checked the data more carefully.
“I’ve asked myself many times how I would have done it differently,” Caper said of his preparation of the original editorial. “I certainly would have called them and said, ‘Here’s what our study shows. Does that appear screwy to you?’
“It was an honest mistake on their part in reporting the ZIP codes. And I think it was an honest mistake on my part,” Caper said.
Caper added that he hopes the controversy doesn’t harm efforts to make health statistics more accessible to the public.
“This whole question of the use of data is an emotional question and it’s politically loaded,” Caper said. “The doctors and the hospitals used to have exclusive control over the data. What’s happening now is that the purchasers of care are saying, ‘It’s our data too.’ And I’m afraid this will be used as an attempt to derail the effort to get the data into the public sector.”
Carmichael said he is still worried about damage Caper’s editorial may have caused to a cardiac surgery program that at 2.6% had one of the lowest mortality rates in the state in 1985, the year of Caper’s study.
But Scripps officials are hard-pressed to provide firm evidence of any harm from the editorial. The damage comes more in public perception of the institution, Carmichael said.
“It hurt us in a lot of subtle ways,” Carmichael said. “Suddenly there’s a shadow cast on your program. I don’t care how you recant something like this, you always have a sort of an odium attached to your program when something like this comes out in a place like the New England Journal.”
