Editors’ note: Hospitalists face difficult decisions every day, including situations that don’t always have clear-cut answers. Beginning with this month’s “HM Debate,” The Hospitalist stares down the tough questions and presents all sides of the issues. This month’s question: You are discharging a patient after treatment for a non-ST segment myocardial infarction (NSTEMI). The cardiology team recommends nonemergent coronary artery bypass grafting (CABG) for the patient’s three-vessel disease. You set up a referral for surgery, but you know the CABG morbidity and mortality rates are higher at your hospital than at a hospital 30 miles away. Should you disclose this information to your patient?
If you would tell your relative, you should tell your patient
If a patient at your hospital needs surgery or another invasive intervention, are you obligated to inform them of your hospital’s record with that procedure—particularly if the record is not as good as the one of the hospital down the street? Should loyalty to your hospital trump the risk to the patient?
In our scenario, the patient is being referred for elective surgery, and it is known that the cardiovascular team at a neighboring hospital has a better record for this procedure. It is the hospitalist’s job to present this information to the patient so that an intelligent and informed decision can be made. If the hospitalist believes the outcomes data, then an obligation exists to share that information with the patient.
If the data are subtle, one might argue that confusing the patient with more levels of decision-making is unnecessary. On the other hand, if data on performance outcomes between two institutions are clear, it presents an ethical position.
Let us assume the hospitalist is aware of poor outcomes in coronary bypass surgery at their hospital. Perhaps the mortality rates were unusually high and the hospitalist knew external consultants were brought in to identify the problems. Would you refer your patient for bypass surgery in that situation? A better question might be: Would you let a family member undergo coronary artery bypass grafting (CABG) in your hospital? Probably not. So if you would inform a family member, shouldn’t you tell your patient?
A situation like this occurred in September 2005 at the University of Massachusetts Medical Center in Worcester. Media coverage was intense, and statistics showed that thoracic surgery mortality at UMass was the highest in the state two years running. The service at the hospital was closed temporarily.1 Extensive reorganization, adoption of QI protocols, and development of oversight committees resulted in much-improved patient outcomes when the program reopened a few weeks later.
The higher-than-expected complication rate had persisted at UMass for four years before the closure and reorganization. One wonders if hospitalists and cardiologists suspected a problem with surgical outcomes before the hospital was thrust into the national spotlight. Is it our job to know our hospital’s track record in surgery and invasive procedures? Yes, it probably is. This is why a hospital’s quality-assurance committee is so important. As keeper of the outcomes data, the committee is charged with sounding an alarm when a problem is brewing.
Tech-savvy patients have access to detailed reporting on performance measures for hospitals and physicians. Interpretation of the data can be complex. High surgical complication rates might be the result of a higher-than-expected patient acuity mix—patients who were older and sicker than usual—and may not represent a system or surgeon problem. Hospitalists need to guide patients through the interpretation of this data.
Patients trust their physicians. They trust that hospitalists will provide the best advice and make recommendations with their interests at heart. To not do so violates the public trust in physicians as patient advocates. Required by law, transparency of hospital quality data is the basis of a truthful relationship between the healthcare system and the public.
HM’s reputation will be tarnished if patients perceive that the physicians are more interested in the well-being of the hospital than the well-being of the patients.
- Kowalczyk L, Smith S. Hospital halts heart surgeries due to deaths. Boston Globe Web site. Available at: www.boston.com/news/local/articles/2005/09/22/hospital_halts_heart_surgeries_due_to_deaths. Accessed March 31, 2009.
Outcome disclosure is impractical, unnecessary
At first glance, disclosing information about better outcomes at another hospital seems reasonable—even ethically obligatory. However, there are several competing interests, and in the end, the existing precedent for requiring reasonable disclosure in informed consent makes more sense.
The first issue is practicality. How much is a hospitalist obligated to know, and what degree of difference must be disclosed? In the case example, the hospitalist knows better outcomes are available at a nearby facility. However, if a duty to disclose this information exists, it can’t be limited to the information that an individual hospitalist has available to them. If such a duty exists, there is a corresponding burden on providers to have consistent and accurate information to disclose. If disclosure of differing outcomes is the ethical standard, then the reasonable disclosure needs to meet some uniform criteria for when a differing outcome rises to the level that the disclosure is compelled.
Data exist for pneumonia outcomes, readmission rates, and medication errors, as well as data for physicians relative to their colleagues. The fact that a hospitalist might have incidental knowledge of differing outcomes is not sufficient to create an ethical obligation, but there must be some uniformity to a disclosure requirement.
It is easy to envision a hospitalist spending as much time disclosing outcomes data as disclosing medical information and prognosis in the process of obtaining informed consent. Hospitalists can’t be expected to manage all of that information, much less make a meaningful disclosure. Physicians’ information-management skills should focus on medical knowledge—not outcomes data.
The test case has more implications for the professionalism of the hospitalist. Ultimately, they should act in the best interest of the patient. The recommended course of treatment should maximize benefit and minimize harm. Enough information should be provided that the patient can participate in weighing risks and benefits. The hospitalist needs to decide if it is unsafe to perform the procedure at their institution, and if so, the patient should be referred out. If there is a small but real benefit to having the procedure done elsewhere, the hospitalist cannot be responsible for determining what threshold of incremental benefit warrants disclosure. Existing ethical responsibilities to protect the patient and act in their best interests already addresses the issues of disparate outcomes more effectively than a blanket disclosure policy. Patients need to trust their hospitalists, and we need to be worthy of that trust.
Mandating disclosure of better outcomes would create a conflict of interest for physicians and hospitals. This conflict would be difficult to manage. Large referral centers exist because physicians recognize their own limits and act in patients’ best interests. Requiring a new level of disclosure would mean that many hospitals (save for an elite few) would recommend patients go elsewhere a substantial part of the time.
Conflicts of interest usually are managed more than eliminated, and the current management of the tension between caring for a patient personally and referring them out based on a perception of the patient’s need for a higher level of care achieves a reasonable and balanced result. Disrupting this result with a mandated level of disclosure will result in disruption of a functional process.
Measured disclosure of relevant information is a good thing. A high level of communication and shared decision-making between physicians and patients is a good thing. Discussion of disparate outcomes may be an ethically important part of a treatment plan, but saying it is advisable in all cases is unnecessary, unmanageable, and inadvisable.
The opinions expressed herein are those of the authors and do not represent those of the Society of Hospital Medicine or The Hospitalist.