- centerforhealthreporting.org/project/high-rates-california-heart-procedures-raise-cost-health-quality-concerns
- centerforhealthreporting.org/blog/series-variation-sparks-intense-varied-response
- centerforhealthreporting.org/blog/online-comment-spurs-reporting-about-risky-surgery737
- bit.ly/zSft5q
Provide names of other journalists involved.
Photographer: Free-lancer Brian Baer
List date(s) this work was published or aired.
Sept. 4, 5, 2011
Provide a brief synopsis of the story or stories, including any significant findings.
Residents of the poor and isolated Northern California community of Clearlake undergo two common heart procedures at exorbitant rates, between five and six times more than average Californians. This was the conclusion of a complex data analysis that showed dramatic variation across California in the use of elective angioplasty and elective angiography. The analysis also drove home the point that where you live can help determine how likely you are to go under the knife. Residents of broad swaths of California’s Central Valley also undergo these heart procedures at high rates, but the biggest disparities were in Clearlake, a down-and-out region known equally for its high drug use and its huge freshwater lake. In my Day 1 main bar, I focused on the data findings and sought to explain why Clearlake’s rates were so high. Was it, as the local hospital suggested, because the region’s population is sicker than other Californians? Or was it, as experts in medical variation opined, differences in how aggressively doctors in that area treat diseases? The vast majority of Clearlake residents who get these procedures go to St. Helena Hospital in St. Helena, so I focused my reporting on that hospital, and on the Clearlake cardiologists whose practice is owned by the hospital. Day 1 also included a sidebar– a consumer-friendly Q&A about angioplasty and angiography– and graphics. We made the cardiac data set available to readers on our website using a downloadable database, as well as the methodology. The main bar for Day 2 focused on real-world efforts to rein in medical variation by a Northern California accountable care organization. In this effort, an insurer, hospitals and physicians in the Sacramento region worked on reducing variation in procedures such as hysterectomy, both to save money and improve patient care. Day 2 also included a short sidebar describing the ACO’s efforts to reduce weight-loss surgeries by requiring patients to attend a six-month-long series of classes before undergoing the procedure. Many opted against the procedure after attending the classes.
Explain types of documents, data or Internet resources used. Were FOI or public records act requests required? How did this affect the work?
This project was built on data. The primary data analysis was conducted by Stanford Professor Laurence Baker, who crunched five years (2005-2009) of statewide hospital (and some outpatient) discharge data from California’s Office of Statewide Health Planning and Development, or OSHPD. Baker looked at the use of 13 procedures, from hip replacements to mastectomies, across the state, breaking the data into established medical geographies known as Hospital Referral Regions and then into smaller Hospital Service Areas. I mined Baker’s analysis to find regional discrepancies and delved into the minutiae of his risk adjustments to determine whether he adequately controlled for differences in the health and economic status of local populations. Baker’s analysis didn’t include where patients underwent procedures. So, I worked with OSHPD to replicate part of Baker’s data run, this time tying the procedures to facilities. This data dive showed me that more than 90 percent of Clearlake area residents were going to St. Helena Hospital, at least an hour away, for the procedures With the help of my editor, I also turned to The Dartmouth Atlas of Health Care. The Atlas specializes in tracking patterns in Medicare usage, and through its online database, we discovered that in 2005, 2006 and 2007, the three most recent years for which data are available, Clearlake had the highest inpatient angioplasty rate in the country. I submitted a FOIA request to CMS to unearth Medicare’s hospital reimbursement rates for the cardiac procedures at 12 California hospitals, but those figures did not end up figuring prominently in my final story.
Explain types of human sources used.
My human sources varied widely and included academics who specialize in angioplasty, John Wennberg, the founder of The Dartmouth Atlas (and other experts in medical variation), hospital administrators, pastors, local residents who have received these procedures and doctors.
Results:
We heard from doctors and researchers from around California and the country who were interested in the data and wanted to mine it for more information. Residents of the Clearlake area, including some local doctors, reached out to share concerns about St. Helena Hospital or describe personal experiences. I described some of these and other responses in a blog posting. San Francisco Chronicle readers posted 130 online comments to the main story. One was from a Bay Area resident whose father had recently died from a surgery-related complication at St. Helena Hospital. His father, a Clearlake-area resident, had undergone a risky stroke-prevention procedure called carotid endarterectomy, but the procedure triggered a stroke instead, which is a rare, but known, complication. The reader was upset, he wrote, because he wasn’t convinced the surgery was necessary. My antennae shot up when I read his comment, because questions about whether procedures are necessary are central to medical variation. It turns that out that, according to Baker’s analysis, residents of the Clearlake area also get these stroke prevention surgeries at high rates. They undergo them at the second-highest rate in the state– about 2½ times more than average Californians. My colleague, broadcast reporter Kelley Weiss, and I teamed up to learn more. We ended up producing print and broadcast stories about the Magner family’s story and how it fits into medical variation. The stories ran Jan. 16 and 17, 2012, in The San Francisco Chronicle and on KQED’s California Report.
Follow-up (if any). Have you run a correction or clarification on the report or has anyone come forward to challenge its accuracy? If so, please explain.
No.
Advice to other journalists planning a similar story or project.
The first thing a reporter should do is understand geographic variation, a phenomenon that has been well-documented by The Dartmouth Atlas, Atul Gawande and others. Early on, a source urged me to read “Tracking Medicine,” by Wennberg. Wennberg’s book is a must for anyone interested in variation, and drove home some key, seemingly counterintuitive, conclusions. One is this: Even though hospitals and doctors often blame variation on differences in regional populations– from their health conditions to income levels to access to health care– that generally doesn’t explain the discrepancies. Instead, research suggests that other powerful factors are at play, in particular differences in how doctors treat diseases, especially when they have discretion in how to treat illnesses.