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Ann Thorac Surg 2007;83:1918
© 2007 The Society of Thoracic Surgeons
Department of Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425
(Email: kratzj{at}musc.edu).
Our institution was recently contacted with a request for permission to allow The Society of Thoracic Surgeon’s (STS) National database to release information for our program from the database to an insurance company. The stated goal was to use this information to measure quality improvements of our programs versus other programs in their designation of certain cardiac programs as "Premium Cardiac Hospitals." The leadership of The STS has decided that this release of information is appropriate if the individual programs agree to the release of their data. Initially this seems like an excellent way to assure that insurance companies use accurate and appropriate data to evaluate cardiac surgery programs. However, on further thought, participation in this type of activity could lead to the destruction of an accurate STS database.
Obviously submission of correct data by the participating programs is key to an accurate and useful database. The STS database exists on voluntary submission of accurate data. Two factors that may drive a physician’s behavior or an institution’s decision in providing data are morality and financial incentive. In the past, the goal of participating institutions was to provide and obtain information that would allow that institution to evaluate and improve the quality of care. The privacy of each individual institution’s results has been carefully protected, preventing inappropriate incentives from creeping into the system that would perhaps cause intentional or unintentional corruption of the submitted data. We are now being asked to share our data with companies who will inevitably use this data to the financial betterment or downfall of the submitting programs. This addition of financial incentive may lead to the loss of accuracy of the database we have all worked so many years to build.
Can hospitals and doctors be relied upon to provide accurate data when their financial success depends on the data submitted? In many cases submitted STS data is collected by employees of hospitals. With reports of Tenet paying $725,000,000 and Hospital Corporation of America paying $631,000,000 in fines to the United States government for fraud, can accurate voluntary reporting of complications by large hospital corporations be assumed? In other cases, data for submission to The STS database is collected by employees of physicians. Given the multimillion dollar settlements paid by academic physician group practices to the federal government for charges related to billing practices, can we be assured of accurate data reporting by physicians in the face of financial incentives?
Financial incentive may lead to dishonesty. In financial dealings, data must be audited to assure accurate reporting. I trust my bank, but would not fail to balance my checkbook monthly to be sure our records agree. No reasonable person would invest in a large corporation that failed to have auditors examine the books regularly. Even the federal government sends the GAO around to be sure our dollars are spent properly. The STS does audit programs for accurate data collection. However, out of approximately 600 programs, the STS is only able to audit 24 programs per year. Thus any given program may expect an audit approximately once every 24 years. When problems are detected, the program is not publicly identified. The program is worked on to bring it into conformance. These measures hardly seem stiff enough to be assured that the temptations of financial incentives will not lead to inaccurate reporting by some parties. Apparently The STS already expends a quarter of a million dollars per year in the audit process. An audit process intense enough to assure accurate reporting would seem financially impossible.
We have until this time probably enjoyed a reasonably accurate STS database by avoiding incentives that would encourage bad reporting by participating programs. A similar situation is found in blood collections by the Red Cross. Recognizing the key to a safe blood program is the voluntary reporting by donors of dangerous activity or exposure for which the Red Cross has avoided financial reward for donations. Our database is a superb tool allowing for a steady improvement in the quality of cardiac surgery and should not be compromised. Our leadership has decided that the need for an accurate and good tool allowing insurance companies to compare the quality of various cardiac surgery programs is worth the risk of damaging the database; they have made this decision with the best interests of our profession in mind. I however disagree, believing that the possible risk of damage to the integrity of the database is too great to take this risk. Other ways should be found to provide insurance companies with accurate and meaningful data without subjecting the STS database to the effect of financial incentives on data reporting. An active and brisk dialogue within the STS is needed to resolve these issues.
Related Article
Ann. Thorac. Surg. 2007 83: 1918-1919.
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 F. L. Grover Reply Ann. Thorac. Surg., May 1, 2007; 83(5): 1918 - 1919. [Full Text] [PDF]
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