Feasibility of Report Cards for Measuring Anesthesiologist Quality for Cardiac Surgery.
BACKGROUND
In creating the Merit-Based Incentive Payment System, Congress has mandated pay-for-performance (P4P) for all physicians, including anesthesiologists. There are currently no National Quality Forum-endorsed risk-adjusted outcome metrics for anesthesiologists to use as the basis for P4P.


METHODS
Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 55,436 patients undergoing cardiac surgery between 2009 and 2012. Hierarchical logistic regression modeling was used to examine the variation in in-hospital mortality or major complications (Q-wave myocardial infarction, renal failure, stroke, and respiratory failure) among anesthesiologists, controlling for patient demographics, severity of disease, comorbidities, and hospital quality.


RESULTS
Although the variation in performance among anesthesiologists was statistically significant (P = 0.025), none of the anesthesiologists in the sample was classified as a high- or low-performance outliers. The contribution of anesthesiologists to outcomes represented 0.51% of the overall variability in patient outcomes (intraclass correlation coefficient [ICC] = 0.0051; 95% confidence interval [CI], 0.002-0.014), whereas the contribution of hospitals to patient outcomes was 2.90% (ICC = 0.029; 95% CI, 0.017-0.050). The anesthesiologist median odds ratio (MOR) was 1.13 (95% CI, 1.08-1.24), suggesting that the variation between anesthesiologist was modest, whereas the hospital MOR was 1.35 (95% CI, 1.25-1.48). In a separate analysis, the contribution of surgeons to overall outcomes represented 1.76% of the overall variability in patient outcomes (ICC = 0.018, 95% CI, 0.010-0.031), and the surgeon MOR was 1.26 (95% CI, 1.19-1.37). Twelve of the surgeons were identified as performance outliers.


CONCLUSIONS
The impact of anesthesiologists on the total variability in cardiac surgical outcomes was probably about one-fourth as large as the surgeons' contribution. None of the anesthesiologists caring for cardiac surgical patients in New York State over a 3+ year period were identified as performance outliers. The use of a performance metric based on death or major complications for P4P may not be feasible for cardiac anesthesiologists.
From the *Department of Anesthesiology, University of Rochester School of Medicine, Rochester, New York; †Department of Health Policy, Management and Behavior, School of Public Health, University at Albany, Albany, New York; ‡Department of Anesthesiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania; §U.S. Anesthesia Partners; ‖Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York; and ¶RAND Health, Boston, Massachusetts.
Laurent G
LG
Glance
Edward L
EL
Hannan
Lee A
LA
Fleisher
Michael P
MP
Eaton
Richard P
RP
Dutton
Stewart J
SJ
Lustik
Yue
Y
Li
Andrew W
AW
Dick
D000368:Aged; D000758:Anesthesia / Q000009:adverse effects / Q000191:economics / Q000401:mortality / Q000592:standards*; D002983:Clinical Competence / Q000592:standards; D015897:Comorbidity; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000191:economics / Q000401:mortality / Q000592:standards*; D003625:Data Collection / Q000191:economics / Q000592:standards*; D016208:Databases, Factual; D003695:Delivery of Health Care / Q000191:economics / Q000592:standards*; D005240:Feasibility Studies; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000191:economics / Q000401:mortality / Q000592:standards*; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009518:New York; D016017:Odds Ratio; D016311:Outliers, DRG; D011183:Postoperative Complications / Q000401:mortality; D010818:Practice Patterns, Physicians' / Q000592:standards; D017064:Process Assessment, Health Care / Q000191:economics / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000191:economics / Q000592:standards*; D012052:Reimbursement, Incentive / Q000592:standards; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome