Use of PCI for MI Drops With Public Reporting of Patient Outcomes

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Unintended Consequences

There are three explanations for the observed lack of difference in mortality between reporting and nonreporting states, said Dr. Mauro Moscucci.

First, "futility assessments" in reporting states may have led to avoidance of PCI in patients who were less likely to benefit. Second, public reporting might have resulted in a drive toward improved quality of care and improved outcomes in patients receiving PCI, offsetting the adverse effect of not performing PCI in high-risk patients. Third, the optimal coding of comorbid condition required in risk adjustment may have been gamed through upcoding, thus leading to observed outcomes that are better than predicted. Better coding in public reporting states might have mitigated the adverse effect of denial of care after risk adjustment, he suggested.

This study highlights the possible unintended consequences of public reporting. The findings "may help spearhead a new focus on procedures that, while perceived [to be] appropriate based on current use criteria, might not result in added benefit in selected patients," he added.

Mauro Moscucci, M.D., is chief of the cardiovascular division at the University of Miami. He reported no relevant conflicts of interest. These remarks were taken from his editorial accompanying Dr. Joynt’s report (JAMA 2012;308:148-9).



The use of percutaneous coronary intervention for acute myocardial infarction was found to be lower in three states that implemented public reporting of PCI outcomes than in seven nearby states without public reporting, according to a study of nearly 98,000 cases in the October 10 issue of JAMA.

In addition, the use of PCI for acute MI declined in one state after public reporting of PCI outcomes was implemented there, said Dr. Karen E. Joynt of the departments of health policy and management at Harvard School of Public Health, Boston, and her associates.

Nevertheless, public reporting was not associated with any change in mortality for patients with acute MI in this study, they noted.

Collecting and publicly reporting patient outcomes is a tool intended to improve health care by motivating clinicians to improve their performance and allowing patients to choose the highest-quality hospitals. Critics of this strategy, however, say that it creates disincentives for physicians and hospitals to care for the sickest patients and may lead them to avoid offering lifesaving procedures such as PCI to the sickest or highest-risk patients.

To date, no national studies have examined whether public reporting of PCI outcomes has affected either the rates of PCI or the outcomes in patients with acute MI. Dr. Joynt and her colleagues did so using data from Medicare files.

They first performed a cross-sectional analysis of PCI rates in 30,745 patients who had a discharge diagnosis of acute MI in a single year, 2010. They compared the rates in three states that mandated public reporting – Massachusetts, Pennsylvania, and New York – against rates in seven nearby states that did not (Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland, and Delaware).

Patients in the public-reporting states were significantly less likely to receive PCI (37.7%) than were those in nonreporting states (42.7%). This trend was most pronounced in MI patients who had ST-elevation MI, cardiogenic shock, or cardiac arrest and was not seen in patients with non–ST-elevation MI, the investigators said (JAMA 2012:308;1460-8).

When the patients were categorized by age – 65-74 years vs. 75 years and older – the results were the same: Regardless of their age, patients in publicly reporting states were less likely to receive PCI than were those in nonreporting states.

The researchers then performed a longitudinal analysis of trends in PCI rates for 49,660 acute MI patients in reporting states and 48,142 in nonreporting states who were treated in 2002-2010. They focused on the experience in Massachusetts, tracking the rates before public reporting of PCI was implemented there (2002-2004) with the rates after it was implemented (2006-2010).

Before public reporting of PCI was implemented, the PCI rate in Massachusetts (40.6%) was comparable with that in nonreporting states (41.8%), but PCI rates in Massachusetts began to decline when reporting was implemented and by 2010 patients in Massachusetts were significantly less likely to receive PCI than were those in nonreporting states.

As in the cross-sectional study, PCI rates in Massachusetts declined the most among MI patients who had cardiogenic shock or cardiac arrest, and these findings did not change when patients were categorized by younger vs. older age.

Despite these declines in PCI rates, there was no significant difference in 30-day mortality between acute MI patients in reporting states (12.8%) and those in nonreporting states (12.1%). Some may find it reassuring that mandating public reporting did not increase patient mortality, but, conversely, it also did not reduce mortality, the researchers said.

Although the study was not designed to find out why mortality was not affected by reductions in PCI rates, Dr. Joynt and her associates proposed two explanations.

First, it may be that public reporting had its intended effect of focusing clinicians on performing PCI in only the most appropriate patients, and that they correctly avoided doing it in cases in which it would have been futile or unnecessary.

Alternatively, it’s possible that public reporting had an unintended effect of pressuring physicians to avoid PCI in eligible but high-risk patients because of concern that poor outcomes would color their performance rating.

"Our data cannot definitively differentiate between these two potential mechanisms," the investigators said.

This study was supported by the National Heart, Lung, and Blood Institute. No financial conflicts of interest were reported.

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