| Popis: |
Purpose: Empirical evidence on impact of CABG report cards on the quality of CABG surgery is patchy, mixed and mainly comes from uncontrolled and short term studies. CABG report cards are associated with a small decline in mortality after controlling for an overall declining trend. Whether report card publication has caused this decline is not known. Methods: I use difference-in-differences and difference-in-differences-in-differences with fixed and random effects in OLS, Logistic, FGLS and GMM regression frameworks in a quasi-experiment set up in State-level and patient-level HCUP data with risk-adjustment to assess long term impact of CABG report cards on CABG mortality and provider market share and volume. This study uses counterfactuals, and multiple States as treatment and control States. Results: CABG shows steadier and 17% steeper decline in in-hospital mortality rate when compared with other equally complex surgeries, and 30% steeper improvement when compared with pneumonectomy. There is a strong secular and statistically significant trend of decreasing CABG mortality. States with and without report cards were similar in terms of CABG mortality at baseline. We do not see long term impact of CABG report cards, State-mandated or voluntary, on CABG in-hospital mortality. Nevertheless, report cards have caused a gain in market share of 6% and 5% for low mortality hospitals and surgeons respectively in face of a secular trend of rising market share of average mortality hospitals and surgeons. CABG report card policy was also associated with decrease in hospital volume by 152 surgeries and decrease in surgeon volume by 14 surgeries a year over and above the secular trend of declining CABG volumes. Conclusions: Concurrent Society of Thoracic Surgeons intiative and spillover of effects across States may explain why we do not see impact of CABG report cards in long term on improvements in quality of CABG surgery. National and regional system interventions with State CABG report cards appear to have created a perfect storm leading to a rising tide of CABG quality which has benefitted all States. It appears the report cards are associated with a change in today's culture of medicine biased in favor of interventions and procedures. |
