Topol E J, Califf R M
Department of Cardiology, Cleveland Clinic Foundation, OH 44195.
Ann Intern Med. 1994 Jan 1;120(1):65-70. doi: 10.7326/0003-4819-120-1-199401010-00011.
Public release of operator-specific data for cardiovascular procedures has set a new precedent, introducing the "scorecard" era. Justification exists for public disclosure, but the mechanics of appropriate data release are complex from a clinical, statistical, and logistic standpoint. Scorecard medicine may appropriately promote regionalization of medical centers and consolidation of services, but unless the process is directed effectively, it may impair the development of new treatments because of a more restrictive clinical practice environment. We propose revamping our current system to facilitate rapid and accurate access to outcome data in the local practice environment so that improvement in practice occurs on a voluntary basis rather than in response to punitive restrictions. A rational plan needs to be developed for dealing with high-risk patients, perhaps through compensation in regression models used to calculate expected outcomes, and for the start-up of novice physicians. Special provisions are needed to promote clinical research. Before procedures are done, it would be ideal to provide a full disclosure informed consent, whereby the physician reports operator-specific data and the patient's decision-making process is facilitated. Overall, appropriate implementation of scorecards could ultimately lead to a substantial improvement in the quality of U.S. cardiovascular medicine.
心血管手术中特定术者数据的公开发布开创了一个新的先例，开启了“记分卡”时代。公开披露有其合理性，但从临床、统计和后勤角度来看，恰当的数据发布机制很复杂。记分卡医学可能会适当地促进医疗中心的区域化和服务整合，但除非有效引导这一过程，否则由于临床实践环境更具限制性，它可能会阻碍新治疗方法的发展。我们提议改进当前系统，以便在本地实践环境中快速准确地获取结果数据，从而使实践改进基于自愿而非应对惩罚性限制。需要制定一个合理的计划来处理高危患者，或许可以通过在用于计算预期结果的回归模型中进行补偿，以及针对新手医生的起步阶段。需要特殊规定来促进临床研究。在手术进行之前，提供一份全面披露的知情同意书是理想的做法，即医生报告特定术者数据，并促进患者的决策过程。总体而言，记分卡的恰当实施最终可能会大幅提高美国心血管医学的质量。
