A few months back, we admitted a patient we’ll call Mr. Jones to the hospital for a severe gastrointestinal bleed. We had discharged him two weeks earlier after he had come in with a heart attack and made sure he was on aspirin to prevent future cardiac events. He dutifully took his aspirin and on the day of the readmission, had a massive bleed. He made it to the hospital barely alive and an endoscopy in the ICU showed an active bleeding gastric ulcer. For Mr. Jones, the gastrointestinal bleed, likely brought on by the aspirin, was an “unintended consequence” that almost killed him. Yet no one questioned whether we should have given him aspirin in the first place. I felt terrible about what had happened but found solace in knowing that while for some patients the risks of aspirin are worse than the benefits, for the general population of people like Mr. Jones, the benefits are clearly worth the side-effects.
We do risk-benefit analyses every day in clinical care, knowing that for some patients, the benefits will be outweighed by the harm. We try to be thoughtful about who might be hurt or not, but most of the time, we just can’t predict. So, when the benefits appear to outweigh the risks, we move forward and try to learn from cases like Mr. Jones.
While this kind of risk-benefit analysis is common in clinical practice, it’s unfortunately not how we discuss health policy interventions. No policy intervention is ever without risks, and it is rare that a new policy will have no side-effects at all. Yet, every time policymakers put in a new initiative, they sell it as a panacea. Critics, upon finding an unintended consequence, then declare the whole thing a failure.
An excellent example of this is health information technology, a topic that I have blogged about in the past (here and here). Proponents only talk about its benefits, allowing critics to highlight every shortcoming and failure. Thank goodness I don’t have to deal with proponents and critics like that every time I consider prescribing aspirin to my patients.
From this backdrop comes an important new JAMA study by Dr. Karen Joynt (on which I was senior author). We examined what happens to patients with an acute myocardial infarction in states that have public reporting of outcomes for patients undergoing percutaneous coronary intervention (PCI, better known as angioplasty and stenting). Three states have instituted mandatory public reporting of outcomes for this procedure.
Proponents of public reporting argue that transparency will motivate poor performers to improve and provide information that consumers can use to choose the best providers. However, it was not without controversy. The critics voiced concern that public reporting would lead to denial of care for the sickest patients because doing so could make physicians’ mortality statistics look worse. Whether public reporting leads to better care, unintended consequences, or both is an empirical question – a question our research team wanted to answer.
So what was the punch line? We found that public reporting was associated with reduced access to PCI for patients who had a heart attack. Stated simply, in states with public reporting of angioplasty outcomes, heart attack patients were less likely to receive this life-saving procedure. This was especially true among the sickest patients (the ones who probably benefit the most). Even more concerning, there was a trend towards higher mortality for heart attack patients in public reporting states, presumably because they were less likely to receive this life saving therapy (this effect was small and not consistently statistically significant). This was clearly an unintended consequence, and a bad one at that.
Transparency – making outcomes public so patients have access to information – clearly has its upsides as well. There’s evidence that public reporting of PCI has led to lower procedure complication rates, presumably because providers are being more careful. There’s evidence from cardiac surgery that public reporting pushed some of the worst performing surgeons to stop doing surgery altogether. While difficult to measure, making the healthcare system more transparent to patients has its own benefits in terms of increased trust.
The lesson to draw from our paper in JAMA is that no policy, no matter how well intentioned, is without side effects. Our job is to think about how to minimize those side effects. We could improve risk-adjustment methods so that cardiologists get more credit for performing PCI on the sickest patients. We could carve out some exceptions from public reporting, as Massachusetts has been trying to do, as a response to this kind of data. Or, ultimately, we can hope that over time, physicians get used to public reporting and simply do what is right for their patients.
When aspirin was first tested in heart attack patients nearly two decades ago, large randomized, controlled trials were conducted, giving us precise estimates of both the benefits and harm. We could make thoughtful clinical decisions about whether it was worth it or not and in whom. Most health policy interventions are not tested rigorously before they are implemented. That’s why we need robust health policy research after policies go into effect. We need these studies not to discover whether there are any unintended consequences – there usually are – but rather, to quantify the benefit and the downsides so that we as a society can make thoughtful decisions about whether the policies are worth it or not. Despite the fact that Mr. Jones had a horrible complication from aspirin, I will continue to prescribe it to my heart attack patients. Despite the fact that transparency seems to reduce access to PCI for critically ill patients, I will continue to advocate for it in healthcare. The question we now need to ask is how can we do it in ways that lets us maximize the benefit and minimize the harm.