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Change in public reporting standards may lead to greater use of PCI
A new study highlights an increase in the use of PCI for cardiogenic shock and a decrease in in-hospital mortality after a 2006 change in public reporting of PCI risk-adjusted mortality analyses that excluded patients with cardiogenic shock in the state of New York.
“The drop in mortality that we observed suggests that changing the policy to exclude the sickest patients changed physician behavior and may have improved public health,” Robert Yeh, MD, MSc, interventional cardiologist, director of the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center and associate professor of medicine at Harvard Medical School, said in a press release. “Our previous work found that elderly patients or those presenting with shock or cardiac arrest were even less likely to undergo a potentially lifesaving procedure in states with public reporting.”
Robert Yeh
A number of states, including New York and Massachusetts, mandate public reporting of mortality outcomes following certain cardiac procedures. In 1992, New York became the first U.S. state to publicly report mortality outcomes following PCI. The New York Department of Public Health changed the policy in 2006 to exclude patients with cardiogenic shock from the publicly reported PCI risk-adjusted mortality analyses, on the basis of concern that physicians were not treating patients in order to avoid risk, according to information in the release.
Researchers analyzed discharge records of 45,977 patients with acute MI complicated by cardiogenic shock from January 2002 through Dec. 31, 2012, in New York and in comparator states including California, Massachusetts, Michigan and New Jersey. Massachusetts is a public-reporting state; the other three are not. The mean age of the patients was 70 years and 40% were women.
“This change in policy in New York provided us with a unique opportunity to study the effects of excluding certain patients from public reporting on physician behavior,” James M. McCabe, MD, medical director of the cardiac catheterization laboratories at the University of Washington, said in the release. “We were able to design a study that compared treatment strategies and outcomes before and after the policy change in New York, and simultaneously compare these to what was happening in other states that did not change their policies.”
Of the 11,298 patients with acute MI and cardiogenic shock in New York, 21,974 (47.8%) underwent PCI during this period. After adjustment for patient factors, PCI was more likely among patients with acute MI and cardiogenic shock in New York after the 2006 changes to public reporting policy compared with before 2006 (adjusted relative risk = 1.28; 95% CI, 1.19-1.37). During the same period, use of PCI increased by 9% in the comparator states (adjusted relative risk = 1.09; 95% CI, 1.05-1.13). “Nevertheless, rates of PCI remained lower in New York compared with comparator states throughout the study period,” McCabe and colleagues wrote in JAMA Cardiology.
Also after the policy change, there was a significantly faster decline in the adjusted risk for in-hospital death among patients with acute MI and cardiogenic shock in New York (adjusted relative risk = 0.76; 95% CI, 0.72-0.81) compared with the comparator states (adjusted relative risk = 0.91; 95% CI, 0.87-0.94).
“There is great enthusiasm for expanding public reporting of procedural outcomes, but the manner in which these policies are implemented can determine whether they ultimately prove beneficial or harmful to patient health,” Yeh said in the release. “We hope this study can help shape future policies aimed at improving both transparency and outcomes for cardiac procedures.” – by James Clark
Disclosure: The researchers report no relevant financial disclosures.