Houston's "Surgeon Scorecard" Results Aren't Pretty

(*See update at the end of this story for a statement from Dr. Amir Malik)

Here's something that you probably didn't know and will soon wish you didn't: Sixteen Houston hospitals saw surgeons perform harmful knee surgeries between 2009 and 2013. The same goes for hip replacements (six hospitals), lumbar spinal fusion (six again) and neck spinal fusion (three).

While we've all heard that there are some hospitals to dodge when you're planning to go under the knife, and others to avoid like the plague if you’re uninsured, what if where you're getting your procedure done isn't as important as who is performing it?

That’s what ProPublica’s recently released “Surgeon Scorecard” suggests. The user-friendly database, which lets the public search by region, hospital or surgeon, takes five years of Medicare billing records and turns all of it into a tool for doctors and patients to learn how 17,000 surgeons compare to their peers.

Here’s how they did it: ProPublica's team looked at the Medicare data and drilled into eight different procedures that are generally considered low-risk and performed on healthy patients, among them knee replacement and hip replacement surgeries. Advised by a panel of doctors, the data whizzes came up with a “rate of complications” for each surgeon, or a number that shows how the professional would perform at a hypothetical, average hospital based upon past performance. "Complications" in past performance include death during an initial surgery, or a patient having to return to the hospital to fix a problem. According to ProPublica, a "high" complication rate means that a surgeon's "patients suffered harm more often than his or her peers."

According to “Making the Cut,” an article that gets to the heart of why all of this matters, just 11 percent of doctors nationally are causing 25 percent of the harm.

Eight Houston-area surgeons whose work falls into the "high rate of complications" category were operating on patients across several hospitals when the data was collected. For example, Dr. Lubor Jarolimek, who earned a high complication rate, performed knee replacement surgery at University General Hospital, Doctors Hospital Tidwell, and St. Anthony’s Hospital.   

Another surgeon, Dr. Amir Malik, whose primary trade is lumbar spinal fusion, the joining of two or more vertebrae in the lower back, also received a high complication rate. Between 2009 and 2013, he worked at Houston Methodist Hospital, Houston Orthopedic and Spine (now Memorial Hermann Orthopedic and Spine), and Memorial Hermann-Texas Medical Center. Stefanie Asin, director of communications at Houston Methodist, said that Malik, along with three other Houston-area surgeons identified by ProPublica as having a "high rate of complications," declined comment.

Update 7/17/15 at 7:00 p.m.

The following is a statement from Dr. Amir Malik:

I am a neurosurgeon and treat diseases of the brain and spine.

The editorial statement relating to a group of surgeons that apparently includes me “(all of whom were also identified as surgeons more likely than most to inflict harm on patients)” is offensive and goes against my basic philosophy as a physician. Because I do not believe I “inflict harm” on my patients. We as Surgeons live by the Hippocratic Creed- First do no harm.

I treat a number of Medicare patients. Some of my patients unfortunately have multiple medical problems before they ever get to me. This increases their risk of complications in the event of surgery.

To characterize a complication as “inflicting harm” on a patient who needed the surgery is an unfair, confusing, and deceptive way to describe my surgical practice. I am in the business of helping people. I could certainly choose to turn away people with pre-existing medical problems, but instead I try to help them while letting them know about the risks associated with procedures performed on patients in their condition. Surgical decisions are made with the consent of the patients. Only then do I to go forward with the surgeries.

The original Pro-Publica article that you draw from is flawed in its methodology (https://www.propublica.org/article/surgeon-level-risk-short-methodology). It selects from a small subset group of patients in any Surgeons database. They utilized a system of Diagnosis codes that signify a Complication. So for example, if a patient was readmitted into the hospital within 30 days of surgery because of wound breakdown, requiring antibiotic treatment, that would classify as a complication. It does not account for the fact whether that same patient was improved in their ‘neurologic function and pain’ and after having their infection treated has improved function and less pain compared to before their surgery. And likewise, vice versa would not trigger the complication threshold and sail under the radar. Because of this very fact, they had to rely on statistical analyses on this data set to draw generalities. That leads to error in interpretation.

Another way to look at it would be the analysis of driving records of 100 drivers. If 20 of them got into an increased number of accidents, it would account for a 20% risk of having an accident for the entire sample set. If further data is then made available on those 20 drivers, eg: age, blood and urine drug levels (alcohol, etc..), it would very quickly become clear that the other 80 in the sample set should not be un necessarily penalized with higher Insurance premiums, because of the smaller high risk subset.

Likewise as Surgeons we treat all comers. To report on a small subset of my practice will obviously skew the entire sample. Therefore, any statement or implication that I have “inflicted harm” on patients who Suffered a complication associated with surgery would be wholly unfounded.

There is another downside to the ProPublica publication, and all other publications of similar nature. It penalizes Physicians/Surgeons unfairly for taking care of high-risk patients. Why would any surgeon risk their reputation if the reward is a slap on the wrist in some article many years later? This, I fear, will over time lead surgeons to opt out of accepting Medicare patients. Which would create an even lesser number of physicians taking care of our ever-increasing elderly population in this country (https://www.nia.nih.gov/research/publication/global-health-and-aging/living-longer).

Amir Malik, MD

(As a side note, the representation towards the end of your article that I “declined to comment" is factually incorrect, as I was never
asked to comment or given that opportunity.)

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