Medical Data a Start, Not the Answer


As electronic health records become the norm, it’s conceivable that an untapped gold mine of medical data will become available for analyses, which will help patients make decisions and doctors improve performance. It’s also likely that the data will raise more questions than are answered, at least initially, and create doubt as much as understanding.

A case in point: Two recent articles in the San Francisco Chronicle (in collaboration with the California HealthCare Foundation Center for Health Reporting) highlighted results of an analysis of statewide hospital data by Stanford Professor Laurence C. Baker. Among other findings, the study found that residents in the rural area of Clearlake, Calif. had the highest rates of angioplasty and angiography in the state – five to six times higher than the state average. It also found that Clearlake had the second-highest rate of carotid endarterectomy – 2.5 times higher than the state average.

What does that tell us about differences in care between regions or between hospitals? For a Northern California man who was profiled in the January 16, 2012 article, it raised fresh questions about the recent death of his father, who suffered a stroke while undergoing carotid endarterectomy at a Clearlake hospital in an attempt to prevent stroke. Did the surgeons there do the right thing? Was his father aware of the risks?

Sherry Boschert/EGMN

Dr. Jeffrey Y. Wang

The medical records noted the indications for carotid endarterectomy in this 79-year-old patient, including a loss of vision due to presumed mini-stroke, the story reported. He’d had two previous stroke-prevention surgeries and a heart bypass. The records also showed that the patient was told the risks and insisted on the surgery. The hospital’s rates of stroke (1%) and death (0.6%) after carotid endarterectomy were lower than the combined 3% rate recommended in national guidelines.

Hospital spokespeople attributed their high rate of carotid endarterectomies to the poor health of the Clearlake population.

What are we to think of all this? While covering the annual meeting of the Southern Association for Vascular Surgery, I asked Dr. Jeffrey Y. Wang for some perspective. Although he couldn’t comment specifically on the newspaper stories, his thoughts highlight the complexity of the issues.

Surgeons may not be the only ones contributing to an area’s procedure rate, he noted. “I don’t know that it’s that the patients are sicker or there’s more disease in one area or the other, although that does come into play. I think it also partially is related to how interested the physicians in that community are about carotid stenosis and stroke, and carotid artery disease,” said Dr. Wang, a vascular specialist at a community hospital, Shady Grove Adventist Hospital in Rockville, Md.

“If you have a primary care group that listens to everyone’s necks and gets ultrasounds on people who have bruits, they’re going to find more disease than those who don’t,” especially asymptomatic disease, he said. “So it’s not like people are coming in with strokes and TIAs left and right,” but they may get a screening exam that detects carotid artery disease, or some other medical problem might spur a carotid duplex ultrasound that detects carotid artery disease.

A companion article in the Chronicle listed questions for patients to ask before major surgical procedures and suggested that many doctors don’t know their own complication rates. Dr. Wang said that because the government is pushing adoption of electronic health records, his own complication rate is very easily available to him. If a patient specifically asks, he will disclose it. Hospital complication rates theoretically are available, although not readily so when a surgeon is advising a patient.

More often, though, patients want to know how many of a particular procedure he has performed. “Especially for a younger surgeon or someone who looks young, there definitely are a lot of questions asked about your level of experience, primarily, ‘How long have you been doing this?’ ” he said.

As far as complication rates, patients usually ask about the risk of complications in general. Dr. Wang tells them the complication rates reported in major, high-quality studies. Using the criteria from those studies, “you can advise patients very well as long as your personal stroke rates and complication rates fall within the same lines,” he said.

--Sherry Boschert (on Twitter @sherryboschert)

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