#1172 1989 · New York State Department of Health · Healthcare / cardiac surgery
New York published every heart surgeon's death rate, and bypass mortality fell 41%
the problem
Patients choosing a heart surgeon had no way to compare which surgeons or hospitals had worse survival odds
background
By the late 1980s, coronary artery bypass graft (CABG) surgery was common enough, and risky enough, that mortality varied widely between hospitals and between individual surgeons within the same hospital — but that variation was invisible to the people whose lives depended on it. A patient referred for bypass surgery had no way to learn whether their assigned surgeon's death rate was near the state average or several times higher; the only entities that tracked outcomes at all were hospitals' own internal quality committees, which reviewed cases privately and had no obligation to warn a future patient away from a struggling surgeon.
New York's Department of Health had the same options every state health regulator had: license surgeons based on training and credentials, investigate individual bad outcomes after the fact, or trust hospitals to police their own surgical staff. None of those addressed the actual gap, which was that even a well-credentialed surgeon could have a meaningfully worse track record than a colleague down the hall, and no mechanism forced that difference into the open before a patient had already chosen.
what everyone would do
Health regulators had two standard levers: credential surgeons more strictly before letting them operate, or investigate individual bad outcomes case by case after a death — both of which left the underlying performance gap between surgeons invisible to the next patient walking in the door, since neither one published a comparable number anyone outside the hospital could see.
what they saw
Reputation had never been reduced to a number patients could compare. Once mortality became a public, rankable statistic tied to a name, avoiding the bottom of that list outweighed any private peer-review warning.
the move
Starting in 1989, New York's Cardiac Surgery Reporting System required every hospital performing CABG surgery to submit patient-level outcomes data, which the state's researchers risk-adjusted for how sick each patient was going in, then published — by hospital, and starting in 1991, by individual surgeon's name. It was the first program in the country to attach a public, numerical mortality rate to identifiable surgeons rather than institutions.
why it works
Once a risk-adjusted death rate is attached to a named surgeon and published, three audiences start reading it that peer review never reached: patients and referring cardiologists who can now simply choose someone else, hospital administrators who don't want a public laggard on staff, and the surgeons themselves, who face a number their own colleagues can see. Risk adjustment was the load-bearing detail — without controlling for how sick each surgeon's patients were, publication would just have taught surgeons to avoid the riskiest cases, which is exactly the failure mode critics later documented at the edges of the system.
the payoff
Risk-adjusted CABG mortality in New York fell 41%, from 4.17% in 1989 to 2.45% by 1992, after the data went public.
where it breaks
It depends on risk adjustment being credible; if surgeons believe the model doesn't fully capture patient severity, the safest strategy becomes turning away the sickest patients rather than operating better, which several studies found happened at the margin in New York and elsewhere. It also needs enough procedure volume per surgeon for a rate to be statistically meaningful, and it works best on outcomes, like death, that are unambiguous — for softer measures the same public-scorecard logic invites gaming the numbers instead of the underlying practice.
what came after
New York's system became the longest-running public cardiac-outcomes program in the US and the direct model for Pennsylvania's, New Jersey's and later national efforts to publicly report surgeon- and hospital-specific outcomes across other high-stakes procedures.
references
- [1]The Decline in Coronary Artery Bypass Graft Surgery Mortality in New York State: The Role of Surgeon VolumeJAMA, 1995pubmed.ncbi.nlm.nih.gov
- [2]NEW YORK STATE CARDIAC SURGERY REPORTING AND QUALITY IMPROVEMENT SYSTEMConnecticut General Assembly, Office of Legislative Research, 2006cga.ct.gov