A contemporary sample of percutaneous coronary intervention (PCI) cases across the U.S. has shown no evidence that treating high-risk PCI cases adversely affects hospital risk-adjusted mortality (RAM), according to a study published Dec. 10 in JACC: Cardiovascular Interventions.

Currently hospital quality is judged by a number of different metrics. Among these forms of appraisal is RAM. Calculated for many different clinical conditions including PCI, these risk-adjustment models have their basis in the belief that mortality, if appropriately adjusted for case mix, can successfully gauge a hospital’s overall quality. However, both hospitals and providers have voiced concern that risk-adjustment models may not adequately account for particularly high-risk clinical features, and that clinicians and hospitals treating a greater number of high-risk patients may have a worse rating.

Evaluating the accuracy of the current ACC CathPCI Registry V4 RAM model, and estimating mortality in moderate- and high-risk subset, Matthew Sherwood, MD, MHS, Division of Cardiovascular Medicine, Duke University Medical Center, and his colleagues assessed whether sites treating more high-risk cases have worse observed versus expected mortality ratios and worse RAM rating than sites treating lower-risk patients.

Examining 624,286 PCI procedures from 1,168 sites that participated in the CathPCI Registry in 2010, results showed that crude in-hospital PCI mortality was 1.4 percent. While the RAM model was generally well calibrated among high risk, there was slight over-prediction of risk in extreme cases. Hospitals that treated the highest overall expected risk PCI patients or those treating the top 20 percent of high-risk cases had lower, and better, RAM ratings than centers treating lower-risk cases (1.25 percent vs. 1.51 percent). The data also showed that the observed/expected ratio for top-risk quintile versus low-risk quintile was 0.91 (0.81 to 0.96) vs. 1.10 (1.03 to 1.17). Even combining all the high-risk patients over a two-year period into a single did not negatively impact the site’s RAM ratings.

The authors note that “with the expansion of public reporting in the U.S., and the potential changes in practice patterns because of these reports, our results have important implications. Dissemination of these data could potentially reassure practitioners, emphasizing that treating the highest-risk patients will not adversely affect RAM ratings. These high-risk patients may be those that benefit the most from intervention.”

Keywords: Academic Medical Centers, Hospital Mortality, Percutaneous Coronary Intervention, Registries, Risk Adjustment

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