Public reporting of PCI may dissuade physicians from treating high-risk patients

Healthcare industry leaders have called for more transparency as a way to assess procedures, improve the quality of care and provide patients with better information when selecting hospitals and physicians. A new analysis, however, raises concerns about public reporting.

In 1992, New York became the first state to publicly report in-hospital risk-adjusted mortality after PCI. Fourteen years later, the state changed course and excluded patients with cardiogenic shock from their publicly reported analysis. Officials noted that some PCI operators avoided treating higher-risk patients because they feared those outcomes would not be as positive as treating lower-risk patients.

Since the policy was updated in 2006, patients in New York were significantly more likely to undergo PCI, according to a recent study published in JAMA Cardiology. After adjustments, the risk of in-hospital death among patients in New York with acute MI and shock decreased significantly faster following the policy change compared with states that did not publicly report risk-adjusted mortality.

Still, the researchers found that New York had consistently lower rates of PCI and revascularization for patients with acute MU and cardiogenic shock than states such as Michigan, California and New Jersey that did not report outcomes to the public.

Ajay J. Kirtane, MD; Brahmajee K. Nallamothu, MD, MPH; and Jeffrey W. Moses, MD, wrote in an accompanying editorial that the American College of Cardiology supported the state of New York’s decision to exclude patients with cardiogenic shock from the calculation for PCI mortality. They noted that those extreme-risk patients might skew the numbers and penalize physicians and hospitals that treat sicker patients. They also added that the rates of PCI and revascularization in New York were lower than expected.

“The consistent finding that rates of revascularization for [patients with acute MI and cardiogenic shock] in New York persistently lag behind those of other non-reporting states remains sobering,” they wrote. “Although stringent criteria for shock are needed to ensure that there is no upcoding or “gaming” of the system, in our experience based on 10 years of observation within New York, the current exclusion (which at least ought to be adopted in states that currently publicly report PCI mortality) still may not go far enough, and these comparative utilization rates support this assertion.”

Kirtane, Nallamothu and Moses wrote that public reporting of PCI mortality tries to help identify variability in care and help physicians and hospitals that are performing below the acceptable standard. As this study showed, though, public reporting could have unintended consequences.

“Even with the recognition that risk adjustment was not enough to mitigate risk aversion, which led to the New York shock exclusion in 2006, this policy change—although perhaps helpful—still did not do enough to encourage physicians to care for the sickest patients who had the most to lose,” they wrote. “These findings should therefore give pause for those who advocate more widespread and indiscriminate public reporting of PCI mortality without careful consideration of the consequences. It may simply be time to recognize that mortality following PCI is the wrong metric with which to arbitrate its quality across heterogeneous patient scenarios, despite attempts to separate these scenarios into discrete entities, such as shock and nonshock.”