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To the Editor:

The Centers for Medicare & Medicaid Services has implemented the Hospital Value-Based Purchasing program this year in an effort to improve the quality of hospital care. The innovative program links health care payments with certain performance outcome measures, providing a financial incentive for quality improvement. The measures that come into effect for 2013 are based on the “clinical process of care” and the “patient experience of care.” An additional set of measures relating to mortality, hospital-acquired conditions, patient safety and inpatient quality are slated to be included in the program for 2014. It is clear that the field of outcomes research is gaining a more prominent role in health care management decisions.

Historically, surgeons always have been at the forefront of outcomes research. These studies are intuitively a more practical alternative to clinical trials. However, the heterogeneity of factors leading to outcomes cannot be understated. Surgical results are a composite of surgical skill and experience, the quality of ancillary support staff and infrastructure, and patient-related factors. Patient-related factors can be summarily divided into modifiable and nonmodifiable risk factors.

The concept of modifiable risk factors presents as much a challenge to the health care system as it does to the patient. The entire onus of health care should not rest with the system that provides it. There are certain factors under the direct control of the patient, such as lifestyle choices, high-risk behaviors and adherence to medication, just to name a few. These are possible confounders when it comes to outcomes and patient surveys. But they are not factored in when making a decision about payment for health care.

Some of the patient-related factors are easy to measure. Glycosylated hemoglobin [HbA1c], for example, can be used as a marker for adherence to antidiabetic medications. HbA1c was found to be a powerful predictor of in-hospital death and morbidity after coronary artery bypass grafting. But how does one quantify the effect of nonadherence to psychiatric medications or missed clinic visits? Does an attitude of noncompliance in one area affect other areas, and ultimately, outcomes?

As the reliance on outcomes data increases, all possible variables will need to be taken into account to make an equitable evaluation of the quality of health care. The contribution of these patient-related factors to outcome has not been well studied and deserves consideration. The “empowered patient” has the right to make his or her own decisions about health care and lifestyle choices, and consequently should share the responsibility for outcomes.

Mohan Mathew John, MD

Surgery Resident

New York City