This article is more than 5 years old. Information may no longer be current.
PCI public reporting programs may confer interventionalist risk aversion
Click Here to Manage Email Alerts
Risk-averse clinical practice patterns were seen in cardiologists in states with current PCI public reporting programs, according to a study published in JAMA Cardiology.
Daniel M. Blumenthal, MD, MBA, instructor of medicine at Harvard Medical School, clinical associate in the division of cardiology at Massachusetts General Hospital and associate chief medical officer at Devoted Health, and colleagues conducted surveys to interventional cardiologists in Massachusetts and New York between November 2016 and February 2017. Massachusetts and New York are two of the states that require public reporting of short-term mortality rates after PCI, according to the study.
Surveys were sent to interventional cardiologists who were identified by an online networking site for physicians, annual surveys of U.S. hospitals and Medicare claims data. Researchers also compared personal and facility characteristics in participants and nonparticipants.
Of the 456 interventional cardiologists who received the survey, 149 participated in the study (mean age, 49 years; 95% men). The overall response rate was 32.7%, with a 51.9% response rate in Massachusetts and 25.1% in New York. Interventional cardiologists practiced in their field for a mean of 18.2 years, and most participants practiced at medium to large hospitals with cardiothoracic surgery capabilities and high PCI volumes.
Participants had a higher median annual volume of PCI procedures performed on patients with Medicare compared with interventional cardiologists who did not participate (31 vs. 17; P < .001).
More than half of participants (59.1%) reported that they sometimes or often felt pressured by colleagues to not perform a PCI if a patient was at high risk for death. In addition, 65.1% of participants noted that they avoided the procedure at least two times due to concern that a negative outcome would be publicly reported.
Interventional cardiologists with more experience were less likely to report pressure to avoid PCI (OR per 1 year of experience = 0.94; 95% CI, 0.9-0.98).
“This suggests that PCI avoidance is not concentrated among a few risk-averse interventionalists,” Blumenthal and colleagues wrote. “While we did not quantify rates of PCI avoidance among clinicians who acknowledged avoiding PCIs, any avoidance of an indicated procedure is concerning. Modifying public reporting systems to include all patients experiencing acute myocardial infarction, as opposed to patients undergoing PCIs alone, is a promising approach for further reducing risk-averse use of PCIs. Interventions designed to support and educate less-experienced clinicians may also help mitigate risk aversion.” – by Darlene Dobkowski
Disclosures: Blumenthal reports he receives consultant fees and/or funding for unrelated work from Devoted Health, HLM Venture Partners, Novartis Pharmaceuticals and Precision Health Economics. Please see the study for all other authors’ relevant financial disclosures.
Perspective
Back to Top
Sunil V. Rao, MD, FSCAI, FACC
This study shows that among clinicians, there is lack of confidence in the public reporting systems. This is important for the future of policy initiatives aimed at improving PCI quality because any successful policy needs to have buy-in from the clinical community.
These findings have big implications. The survey indicates that public reporting appears to result in risk avoidance, which can have real consequences for patients. There was a very vigorous debate on this on Twitter recently and the fundamental question that hasn’t been answered is, “What are we trying to achieve and can public reporting achieve it?” So far, it appears the answer to the first question is elusive and the answer to the second is “no."
We need to go back to the basics and figure out what we are trying to do with quality improvement. That starts with defining what a “high-quality PCI” is, and whether our current systems of documentation help us measure whether a high-quality PCI has been performed.
The study is important and the authors should be congratulated for publishing it.
Click Here to Manage Email Alerts