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Public Reporting of PCI outcome and Physician Behaviour

Two papers in JAMA Cardiology report on the effects of changes in policy of New York public reporting of outcomes of percutaneous coronary intervention. The editorial is available here.

Bangalore et al report on the rates of revascularization for cardiogenic shock in New York before and after the exclusion of cardiogenic shock reporting.  Other states (New Jersey, Michigan and California were comparators).  Propensity score matching was used for analysis.

Abstract

IMPORTANCE

Reduced rates of cardiac catheterization, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) are an unintended consequence of public reporting of cardiogenic shock outcomes in New York.

OBJECTIVES

To evaluate whether the referral rates for cardiac catheterization, PCI, or CABG have improved in New York since cardiogenic shock was excluded from public reporting in 2008 and compare them with corresponding rates in Michigan, New Jersey, and California.

DESIGN, SETTING, AND PARTICIPANTS

Patients with cardiogenic shock complicating acute myocardial infarction from 2002 to 2011 were identified using the National Inpatient Sample. Propensity score matching was used to assemble a cohort of patients with cardiogenic shock
with similar baseline characteristics in New York and Michigan.

MAIN OUTCOMES AND MEASURES

Percutaneous coronary intervention (primary outcome), invasive management (cardiac catheterization, PCI, or CABG), revascularization (PCI or CABG), and CABG were evaluated with reference to 3 calendar year periods: 2002-2005 (time 1: cardiogenic shock included in publicly reported outcomes), 2006-2007 (time 2: cardiogenic shock excluded on a trial basis), and 2008 and thereafter (time 3: cardiogenic shock excluded permanently) in New York and compared with Michigan.
RESULTS Among 2126 propensity score–matched patients representing 10 795 (weighted) patients withmyocardial infarction complicated by cardiogenic shock in New York and Michigan, 905 (42.6%) were women and mean (SE) age was 69.5 (0.3) years. A significantly higher proportion of the patients underwent PCI (time 1 vs 2 vs 3: 31.1% vs 39.8%vs 40.7% [OR, 1.50; 95%CI, 1.12-2.01; P = .005 for time 3 vs 1]), invasive management (time 1 vs 2 vs 3: 59.7%vs 70.9%vs 73.8% [OR, 1.84; 95%CI, 1.37-2.47; P < .001 for time 3 vs 1]), or revascularization (43.1% vs 55.9%vs 56.3%[OR, 1.66; 95%CI, 1.26-2.20; P < .001 for time 3 vs 1]) after the exclusion of cardiogenic shock from public reporting in New York. However, during the same periods, a greater proportion of patients underwent PCI (time 1 vs 2 vs 3: 41.2%vs 52.6%vs 57.8%[OR, 1.93; 95%CI, 1.45-2.56; P < .001 for time 3 vs 1]), invasive management (time 1 vs 2 vs 3: 64.4%vs 80.5%vs 78.6%[OR, 2.01; 95%CI, 1.47-2.74; P < .001 for time 3 vs 1]), or revascularization (51.2%vs 65.8% vs 68.0%[OR, 2.00; 95%CI, 1.50-2.66; P < .001 for times 3 vs 1]) in Michigan. Results were largely similar in several sensitivity analyses comparing New York with New Jersey or California.

CONCLUSIONS AND RELEVANCE

Although the rates of PCI, invasive management, and revascularization have increased substantially after the exclusion of cardiogenic shock from public reporting in New York, these rates remain consistently lower than those observed in other states without public reporting.

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McCabe et al reports on the rates and outcomes of patients with cardiogenic shock after the exclusion policy in the New York public recording model.

Abstract

IMPORTANCE

In 2006, New York began excluding patients with cardiogenic shock from the publicly reported percutaneous coronary intervention (PCI) risk-adjusted mortality analyses.

OBJECTIVE

To examine the effects of the New York shock-exclusion policy change on rates of revascularization and mortality for patients with acutemyocardial infarction (AMI) complicated by cardiogenic shock.

DESIGN, SETTING, AND PARTICIPANTS

This study used several comprehensive statewide hospitalization databases to identify patients with AMI and shock from January 1, 2002, through December 31, 2012, in New York and a series of comparator states (Massachusetts, Michigan, and New Jersey from January 1, 2002, through December 31, 2012, and California from January 1, 2003, through December 31, 2011). Data analysis was performed from October 1, 2015, to March 15, 2016.

MAIN OUTCOMES AND MEASURES

A difference-in-differences approachwas used to evaluate whether the likelihood of receiving PCI and surviving to discharge differed after the policy change in New York in 2006 compared with comparator states that did not enact such
a change.

RESULTS

Among 45 977 patients with AMI and cardiogenic shock (11 298 in New York), 21 974 (47.8%) underwent PCI. The mean (SD) age of the patients was 69.7 (13.2) years, and 18 139 (39.5%) were female. After adjusting for patient factors, patients in New York were significantly more likely to undergo PCI after the public reporting policy changes than they were previously (adjusted relative risk [aRR], 1.28; 95%CI, 1.19-1.37; P < .001) compared with a 9%increase in comparator states during the same period (aRR, 1.09; 95%CI, 1.05-1.13; P < .001; interaction P < .001). Nevertheless, rates of PCI remained lower in New York compared with comparator states throughout the study period. The adjusted risk of in-hospital death among patients in New York with AMI and shock decreased significantly faster after the policy change (aRR, 0.76; 95%CI, 0.72-0.81; P < .001) compared with comparator states (aRR, 0.91; 95%CI, 0.87-0.94; P < .001; interaction P < .001).

CONCLUSIONS AND RELEVANCE

The exclusion of patients with ongoing cardiogenic shock from New York PCI public reports in 2006 was associated with a significant increase in the use of PCI for cardiogenic shock and a concomitant decrease in in-hospital mortality, exceeding simultaneously observed trends in the comparator states. However, rates of PCI
for AMI and shock were lower in New York throughout the study. Alterations in policies related to reporting mortality outcomes after cardiovascular procedures may have significant implications for physician behavior and the public health.

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