How to make a silk purse from a sow's ear

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http://bmj.bmjjournals.com/cgi/content/full/327/7429/1436

 

BMJ 2003;327:1436-1439 (20 December), doi:10.1136/bmj.327.7429.1436

Snakes, ladders, and spinHow to make a silk purse from a sow's ear—a

comprehensive review of strategies to optimise data for corrupt managers and

incompetent clinicians

David Pitches, specialist registrar1, Amanda Burls, senior clinical lecturer1,

Anne Fry-Smith, information specialist1

 

1 Department of Public Health and Epidemiology, University of Birmingham,

Birmingham B15 2TT2

 

Correspondence to: D Pitches d.w.pitches

 

The introduction of performance league tables for UK surgeons and hospitals has

forced them to learn how to present data in the best possible light. Though

there is an urgent need for guidance, official guidelines on how to optimise

performance data are lacking

 

Surgeons' and hospitals' positions in league tables can make or break their

reputations. They therefore need to learn how to present data in the best

possible light. Although some may protest about " sexing up " poor performance

data, " creative accounting " adds a positive spin. In contrast to the plethora of

clinical guidelines, there is still no official advice on how to optimise

performance data, and wide variations in practice persist. This review provides

a timely, evidence based response to the urgent need for guidance.

Methods

We searched Medline for empirical examples of creative accounting (using the

search terms " gaming " , " mortality " , " league table$ " , " upcoding " , " fraud$ " ,

" quality " , and " quality indicators, health care/ " ) and identified 284 papers, of

which we reviewed the most relevant for suitable examples. We also searched the

web with Google using " examples hospital healthcare fiddling figures. " We

included anecdotes from personal experience.

Categories of creative accounting

In addition to fraudulent or biased research, which has been thoroughly reviewed

elsewhere,1 we identified three broad categories of creative accounting:

 

Gaming of non-clinical performance data

 

Fraudulent reimbursement claims

 

Gaming of clinical data.

 

 

Manipulation of non-clinical performance targets

This is particularly important for managers when meeting so called P-45

targets—an expression used by Tony Wright MP while examining Sir Nigel Crisp for

the House of Commons Select Committee on Public Administration2 and meaning

targets for which failure to meet can result in redundancy (in Britain the P-45

is the tax form people receive when leaving employment). A House of Commons

investigation in 2002 uncovered strategies to bring waiting times and numbers of

patients waiting for treatment within national targets.3 Records were altered,

patients were inappropriately suspended from waiting lists, and some hospitals

did not report patients waiting longer than government targets. Though such

techniques are readily exposed, one in 10 healthcare managers admitted to

" fiddling figures " in a recent survey.4

 

 

 

 

More intelligent managers inquire when patients intend to go on holiday and then

offer an appointment during this period. Few patients cancel their holiday for

medical reasons, preferring to postpone their appointment. Since the patients

initiate these delays, their wait is no longer recorded. A related strategy

offers patients non-existent appointments at impossibly short notice to attend;

cancellation shifts them to the back of another list whose waiting times are not

officially recorded. If you identify patients waiting longer than the permitted

limit, you could arrange admission when their consultant is on holiday; then

apologise profusely for the cancellation of their operation and offer a new date

for surgery in the distant future.5

In Scotland the waiting lists record only patients receiving inpatient care. To

reduce the numbers of patients on published waiting lists you should ensure

wherever possible that patients already offered inpatient treatment get treated

as outpatients.6

If you cannot place a patient on an unpublished waiting list, use the date you

periodically update the waiting list, rather than the date of referral, as the

starting point. This can knock several weeks off apparent waiting time.6

Variations include not placing patients on the waiting list until the month of

their appointment or failing to reinstate previously suspended patients.

We applaud advance warning of assessment, as this allows managers time to ensure

that systems are in place to meet targets. We particularly commend the

Department of Health for choosing one week each year to record waiting times in

accident and emergency departments.7 Cancelling unnecessary operations and

keeping extra beds open that week ensures your hospital meets the national

target (90% of patients seen by a doctor within four hours of arrival) at least

once a year. A BMA survey in 2003 found that 72% of accident and emergency

departments introduced exceptional arrangements during the audit week, including

hiring agency staff, introducing double shifts, and cancelling routine

operations.8 This strategy proved highly effective at meeting government

targets: during the audit week 85% of hospital trusts met the target, but the

following week only 63% still met target waiting times.

Another way to shorten waiting times in accident and emergency departments is to

refuse to book in ambulance patients until your clinical staff are ready to

assess them.5 Although patients are on hospital premises, you choose when to

" start the clock, " and until then the patients officially remain under the care

of paramedics (jeopardising their performance targets instead of yours).

Remember to " stop the clock " once you have transferred patients from trolley to

bed since they have now been admitted (even if they remain in the department for

the next two days). Once patients have seen a doctor, discharge them from the

computer rather than wait for their transport to arrive and take them home.5 If

your hospital is full, simply remove the wheels of a trolley to transform it

into a bed, and erect a partition in the corridor to create an " observation

ward. " 9

Academic units are not immune from the need to enhance reputations by

undertaking and publishing trials. If you cannot be bothered to do the research

in the first place you may be able to persuade a journal to publish a trial

under your name that has been conducted elsewhere and published in another

journal. For example, it is intriguing that two randomised clinical trials

comparing surgical techniques should include the same number of patients and

find identical results, despite obviously being carried out in different

hospitals on different continents.10 11

Fraudulent reimbursement claims

You should be aware of the various types of fraud described and prohibited by

law in the United States and elsewhere. The False Claims Act prohibits

misrepresenting the level of care offered or billing for services not rendered.

The Anti-Kickback statute prohibits inducements with the intent to influence the

purchase of healthcare services. Self referrals, in which physicians refer

patients to facilities where they have a financial interest, are outlawed.12

The prospective payment system in the United States, in which healthcare costs

are paid prospectively, based on a standard sum for well defined medical

conditions (the diagnosis-related group, DRG) has created a golden opportunity

to maximise profits without extra work. When classifying your patient's illness,

always " upcode " into the highest treatment category possible. For example, never

dismiss a greenstick fracture as a simple fracture—inspect the x ray for tiny

shards of bone. That way you can upgrade your patient's break from a simple to a

compound fracture and claim more money from the insurance company. " DRG creep "

is a well recognised means of boosting hospital income by obtaining more

reimbursement than would otherwise be due.13

Another reason for upcoding your patients' illnesses is to manipulate

reimbursement rules for your patients' benefit. A recent national survey of US

doctors showed 39% had used such tactics—including exaggerating symptoms,

changing billing diagnoses, or reporting signs or symptoms that patients did not

have—to secure additional services felt to be clinically necessary.14 Medical

fraud is estimated to account for 10% of total US spending on health care (some

$120bn) in 2001.15

Reducing mortality figures—gaming and clinical performance data

Many clinicians worry about public release of clinical performance data, as

above average mortality figures can unfairly damage your reputation. In reality

half of all hospitals have above average (technically, above median) mortality,

and various gaming strategies can help to disguise less than perfect clinical

performance.

Upcoding of morbidities

" Coding creep " refers to the excessive or inappropriate coding of those risk

factors that are required for calculating risk adjusted mortality. A slight

decline in observed mortality from coronary artery bypass graft surgery in New

York in the early 1990s was accompanied by an unexpected rise in the

(calculated) expected mortality. However, 66% of the increase in predicted

mortality was attributed to an increase in the severity of recorded risk

factors.16 Between 1989 and 1991, the proportion of patients recorded

preoperatively as having chronic obstructive pulmonary disease increased from

6.9% to 17.4% (at one hospital this increased from 1.8% to 51.9%). If a major

risk factor is recorded in a higher proportion of patients before surgery the

unit's predicted mortality will increase, as will the likelihood that the unit's

actual mortality falls within or below the expected range.

Clearly smokers have an increased risk of dying during surgery, so any patients

who deny smoking when their history is taken should be questioned further.

Perhaps they stopped recently, they might enjoy a cigarette on social occasions,

or they may share a house or workplace with a smoker—in which case record them

as being a smoker. Similarly, even a faint wheeze in any patient over 40 years

old who has ever been exposed to cigarette smoke could signify early chronic

obstructive pulmonary disease, and patients with this condition have a higher

risk of dying. By placing as many patients as possible in a high risk category,

your figures for risk adjusted mortality will be reduced.

Selection of risk adjustment procedure

When calculating risk adjusted mortality, you can enter a bewildering number of

risk factors into multivariate equations, and many proprietary risk adjustment

formulas are available. Rankings of individual hospitals vary widely depending

on how you adjust for disease severity, and in principle your hospital could

" shop around " for whichever adjustment measure shows it in the best possible

light.17

 

 

 

 

Transfer of patients

The first person to produce a " league table " of hospital mortality was Florence

Nightingale. Her attempts to compare mortality between different hospitals were

widely criticised, not least because she accused certain hospitals of

discharging hopelessly ill patients back home, and she conceded that accurate

statistics were difficult to obtain: " Accurate hospital statistics are much more

rare than is generally imagined, and at the best they only give the mortality

which has taken place in the hospital, and take no cognizance of those cases

which are discharged in a hopeless condition, to die immediately afterwards, a

practice which is followed to a much greater extent by some hospitals than by

others. " 18

Many hospital databases record only those deaths that occur in the hospital of

operation, so deaths in continuing care facilities may be overlooked when

calculating mortality. Conversely, if your hospital seems to have a particularly

high mortality perhaps it is admitting more terminally ill patients. Consider

opening an off-site hospice in order to discharge the sickest patients to die

there.19

Change of operative class

The only major cardiac surgical procedure for which mortality data have been

publicly reported in the United States is coronary artery bypass grafting

(CABG). When confronted with a high risk patient, or if things start going wrong

during an operation, just convert the procedure to an unreported operation.20

Simply adding a few extra stitches can convert a conventional CABG to a CABG

plus mitral valve repair. The apparent mortality in your CABG series falls,

albeit at the expense of more deaths from the (unreported) combined procedure.

You could even invent an entirely new condition by means of computer enhanced

images and allocate your highest risk patients to that category (so called

pixel-byte syndrome21). This could be of particular interest to doctors who are

approaching retirement but who have not yet been credited with an eponymous

syndrome.

Refusing to operate

Despite reassurances that risk adjustment techniques do not penalise surgeons

who operate on high risk patients, an anonymous survey of all cardiac surgeons

in New York state found that 62% had refused to operate on at least one high

risk CABG patient, mainly because of fear of public reporting.22

Cream skimming

It is in the interests of health insurance plans to recruit only the most

profitable patients ( " cream skimming " ).23 One US health insurance company

recruited members at a dinner dance, realising that elderly people who are fit

enough to dance are healthy. Clinicians benefit too from pruning high risk

patients from their lists: for example, doctors who are high outliers can

dramatically improve their profile simply by removing their three patients with

the highest haemoglobin A1c levels.24

Reporting risks

Always report absolute rather than relative risks.25 26 If your hospital's

mortality figure is 6% and the average rate is 4%, you should point out that the

absolute death rate is only 2% higher than average. If people insist on

reporting your unit as having a 50% higher mortality than average, you can

retort that the average is actually only 33% lower.

Discussion

One feature is common to all examples hitherto discussed—the individuals or

institutions that used these techniques were discovered. Further research is

needed to uncover the truly compelling examples of creative accounting. Future

dishonest researchers, incompetent surgeons, and corrupt managers will have to

devise more devious ways to avoid falling foul of the 11th commandment, " Thou

shalt not get caught. "

On a serious note, however, despite claims of widespread gaming and

manipulation, there are comparatively few documented examples. This review

highlights some dilemmas faced by those under pressure to ensure that healthcare

providers conform to performance targets. These include competing targets, in

which achieving success in one area comes at the expense of failing another. We

also demonstrate the consequences of gaming, especially in sensitive targets

such as mortality figures—and where gaming exists, the entire credibility of

targets is undermined

 

 

 

 

 

 

 

 

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