Report cards don't reflect patient variance

Managed care report cards may unfairly penalize providers for patient variances beyond their control, according to a recent study reported in the American Journal of Medicine.

Many managed care organizations impose financial penalties on providers who use "excessive" medical services in treating their patients. However, because these report cards often fail to take into account differences in the severity of illness, such report cards may be misleading.

For example, a hospital that does more blood transfusions for hip fracture surgery patients may have a higher proportion of anemic patients than another hospital that uses fewer transfusions for seemingly similar patients, researchers found.

Researchers conducted a retrospective study of 8,776 charts for hip fracture patients 60 and older who underwent surgical hip repair between 1982 and 1993 at one of 19 study hospitals located in four states. They examined transfusion rates among hospitals, patient characteristics associated with transfusion, and whether those characteristics varied among hospitals.

Postoperative transfusion rates varied from 31% to 54% of hip fracture patients among the 19 study hospitals. Without adjusting for differences in patient severity of illness, four of nine teaching hospitals and two of nine nonteaching hospitals had significantly higher transfusion rates than the reference hospital, while one teaching hospital had a lower rate than the reference hospital.

After adjusting for patient anemia and other clinical variables, only one of nine teaching hospitals had rates higher than the reference hospital instead of the original four. However, four of nine nonteaching hospitals had higher rates than the reference hospital, rather than the original two. In addition, four teaching hospitals and one nonteaching hospital actually had lower transfusion rates than the reference hospital.

(See: Poses RM, Berlin JA, Noveck H, et al. How you look determines what you find: Severity of illness and variation in blood transfusion for hip fracture. Am J Med 1998; 105:198-206.)