White knights appear in many forms, but not often as a study in a medical journal. But the publication of a study this week in the Journal of the American Medical Association may be hailed for swooping in just in time to change the course of a public policy decision that, some neurologist say, would misalign incentives and ultimately harm patients if left as is.
The public policy item is a proposed measure to rank hospitals that treat patients with acute ischemic stroke based on their 30-day mortality outcomes. Similar measures already exist for acute MI, heart failure and community-acquired pneumonia. The models used to calculate those hospital rankings rely on claims data and have been validated against clinical data. The proposed stroke model follows suit by using claims data.
Gregg C. Fonarow, MD, of the Ahmanson-University of California-Los Angeles Cardiomyopathy Center, and colleagues argue that stroke is not like those other conditions. Their concern is that the traditional case-mix variables in an administrative data set don’t adequately discriminate differences in stroke. They tested an alternative model using National Institutes of Health Stroke Scale (NIHSS) scores to capture stroke severity. The results showed that claims-only rankings sometimes placed the best achievers in the dungeon.
“We found in this study that the NIHSS was a more powerful predictor than every other variable combined,” Fonarow said in an interview with Cardiovascular Business. “There is nothing in those other conditions—in heart attack or heart failure or pneumonia—that a single factor has such a tremendous determination on 30-day mortality risk the way we saw with the NIHSS, the severity of stroke.”
Fonarow warned that the stroke measure, which he said has a preliminary nod from the National Quality Forum and is now up for public discussion, conceivably would punish hospitals that take in patients with the most severe stroke. Equally troubling, it might reward hospitals that shun the most needy stroke patients to maintain a high ranking and the financial and reputational benefits that accompany the ranking.
Far-fetched? I think not. As the July cover story in Cardiovascular Business magazine showed, policy decisions such as a fee-for-service payment model provide a powerful incentive to do more but not necessarily better. A measure that can’t accurately identify the top performers from the bottom would confuse if not confound caregivers.
Nor would I discount the angst and elation that follow a low or high ranking. Nearly simultaneous with the publication of Fonarow et al’s study in JAMA, U.S. News and World Report released its lists of top-ranked hospitals. If tradition holds, those top-ranked hospitals will be posting huzzahs on their websites, issuing press releases and running ads in their local media.
Like reimbursement, reputation also is a strong motivator.
As Fonarow said in the interview, their findings are timely and important. Physicians, policy makers and the public don’t always have the information needed to make judicious decisions. On further scrutiny by the scientific community, the JAMA study may not prove to be a white knight at all. But it is good to have the discussion before the measure is initiated.
We’ll keep you posted.
Cardiovascular Business, editor