Risk Aversion in Cardiac Surgery: 15-Year Trends in a Statewide Analysis

Investigators for the Virginia Cardiac Services Quality Initiative

Research output: Contribution to journalArticlepeer-review

13 Scopus citations


Background: With a rising emphasis on public reporting, we hypothesized that select hospitals are becoming increasingly risk-averse by avoiding high-risk operations. Further, we evaluated the association between risk-averse practices, outcomes, and publicly reported quality measures. Methods: Clinical data from 78,417 patients undergoing cardiac surgery (2002-2016) from a regional consortium was paired with publicly available reimbursement and quality data. High-risk surgery was defined as predicted risk of mortality ≥5%. Hospital risk aversion was defined as a significant decrease in both high-risk volume and proportion, with cases stratified by hospital risk aversion status for univariate analysis. Results: The rate of high-risk cases decreased from 17.9% in 2002 to 12.6% in 2016. Significant risk aversion was seen in 39% of hospitals, which had a 59% decrease in high-risk volume vs a 16% decrease at non-risk-averse hospitals. In the last 5 years, declining high-risk cases at risk-averse hospitals were driven by fewer cases from transfers (19.2% vs 28.1%, P < .001) and the emergency department (17.6% vs 19.2%, P = .001). Only non-risk-averse hospitals had mortality rates lower than expected (risk-averse: 0.97 [95% confidence interval, 0.91-1.03], P = .30; non-risk-averse: 0.88 [95% confidence interval, 0.83-0.94], P = .001). There were no differences by risk aversion status in reported ratings or financial incentives (all P >. 05). Conclusions: Over 60% of hospitals continue to operate on high-risk patients, with concentration of care driven by transfer patterns. These non-risk-averse hospitals are high-performing with better-than-expected outcomes, particularly in high-risk cases. Transparency and objectivity in reporting are essential to ensure continued access for these high-risk patients.

Original languageEnglish (US)
Pages (from-to)1401-1407
Number of pages7
JournalAnnals of Thoracic Surgery
Issue number5
StatePublished - May 2020
Externally publishedYes

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine


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