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Rates of invasive treatment for cardiogenic shock lag in NY despite change in public reporting
Invasive treatment for patients with MI and cardiogenic shock has risen in New York state since such cases were removed from public reporting requirements, but still lags behind states without public reporting, according to new findings.
The researchers examined rates of PCI, cardiac catheterization and CABG in patients with MI complicated by cardiogenic shock in New York vs. Michigan. In New York, cardiogenic shock was included in operator-level public reporting until 2005, then phased out on a trial basis in 2006 and excluded permanently in 2008. Michigan does not have public reporting.
Sripal Bangalore
“Being in New York, we are subjected to individual operator-level public reporting and we know from prior data that public reporting at some point in time influenced physician decisions whether to treat or not treat patients, especially [those who are] really sick, such as a patient with cardiogenic shock,” Sripal Bangalore, MD, MHA, director of research, cardiac catheterization laboratory, director, Cardiovascular Outcomes Group and associate professor of medicine at New York University School of Medicine, told Cardiology Today’s Intervention. “Cardiogenic shock was removed from public reporting in 2008, so we wanted to see if that made an impact.”
State comparisons
Bangalore and colleagues compared rates of PCI, invasive management (defined as PCI, cardiac catheterization or CABG) and revascularization (defined as PCI or CABG) in patients with MI and cardiogenic shock in New York and Michigan during three time periods: 2002 to 2005, when cardiogenic shock was included in publicly reported outcomes; 2006 to 2007, when it was excluded temporarily; and 2008 and later, when it was excluded permanently. They also conducted sensitivity analysis comparing rates in New York with those in California and New Jersey, which similar to Michigan do not have public reporting.
The researchers matched 2,126 patients from New York and Michigan via propensity scores (mean age, 70 years; 43% women).
According to the researchers, patients with MI and cardiogenic shock in New York underwent more invasive procedures over time, corresponding with exclusion of cardiogenic shock from public reporting. This was true for PCI (2002-2005, 31.1%; 2006-2007, 39.8%; 2008 and later, 40.7%; OR = 1.5; 95% CI, 1.12-2.01), invasive management (2002-2005, 59.7%; 2006-2007, 70.9%; 2008 and later, 73.8%; OR = 1.84; 95% CI, 1.37-2.47) and revascularization (2002-2005, 43.1%; 2006-2007, 55.9%; 2008 and later, 56.3%; OR = 1.66; 95% CI, 1.26-2.2).
However, the rates for the same procedures in the same population at the same times were higher in Michigan than in New York, Bangalore and colleagues wrote. For PCI, the rates were 41.2% in 2002-2005; 52.6% in 2006-2007 and 57.8% in 2008 and later (OR = 1.93; 95% CI, 1.45-2.56); for invasive management, they were 64.4% vs. 80.5% vs. 78.6%, respectively (OR = 2.01; 95% CI, 1.47-2.74); and for revascularization, they were 51.2% vs. 65.8% vs. 68% (OR = 2; 95% CI, 1.5-2.66).
Comparisons of New York vs. California and New Jersey were similar, according to the researchers.
Lingering effect
The increase over time in New York “suggests a positive impact to removing [cardiogenic shock] from public reporting, but ... the PCI rates for New York lag behind that of non-reporting states, which means there is still a lingering effect of public reporting,” Bangalore said in an interview.
He said the reason is less likely the vestiges of an old stigma and more likely a result of New York’s strict definition of cardiogenic shock, which must be proven before the procedure is begun in order for the case to be excluded from public reporting.
“We know that multiple studies have shown that [public reporting] does guide physician behavior, and we can have these unintended consequences,” he said. “People need to come up with other ways of doing this type of reporting.” – by Erik Swain
For more information:
Sripal Bangalore, MD, MHA, can be reached at New York University School of Medicine, New York, NY 10016; email: sripalbangalore@gmail.com.
Disclosure: The researchers report no relevant financial disclosures.