Public reporting of outcomes after procedures such as percutaneous coronary intervention (PCI) is a topic of much debate and has become increasingly relevant for patients, healthcare providers, insurers, hospitals, and policymakers. There are several reasons for making health-outcomes data more widely available. Public reporting is part of a broader movement to improve transparency in healthcare. Ideally, this information could be used by consumers to make informed decisions in selecting hospitals and individual doctors. Public reporting is also intended to incentivize providers to improve quality of care in ways that enhance health outcomes and patient safety. This information may also be helpful for hospitals and third-party payers to derive cost savings and allocate payment in value-based care systems.¹

Existing Public Reporting Programs

Outcomes related to cardiac care have been at the forefront of the public reporting movement. Beginning with the creation of a reporting system by New York state in 1989, surgeon-specific mortality after coronary artery bypass surgery was one of the first outcomes to be routinely measured at the state level.² Information in this database was released to the public 1 year later by request under the Freedom of Information Act. Public reporting of mortality after PCI began in New York in 1996, was later adopted by Pennsylvania, Massachusetts, and Washington state, and is now being considered more broadly.^3-6 In addition, the Centers for Medicare & Medicaid Services now routinely releases cardiovascular outcomes data that are used to adjust payments to hospitals and providers.⁶ This quality-based model is also being adopted by private insurance organizations.⁷ The Patient Protection and Affordable Care Act of 2010 has further mandated that the Department of Health and Human Services identify appropriate outcomes to be included in public reporting and performance-based payment plans.¹

Evidence Supporting Improvement in PCI Outcomes With Public Reporting

Due to the importance of public reporting in the current era of healthcare, the use of outcomes data after PCI has become particularly important for cardiologists. However, the current evidence of how public reporting of PCI outcomes affects quality of care and patient health is limited. Cavender et al.⁸ evaluated over 1.3 million PCIs nationwide and compared post-PCI mortality between states with mandated public reporting and states without reporting. This investigation showed that patients who underwent PCI in reporting states had lower observed in-hospital mortality than patients in nonreporting states (1.19 vs. 1.41%, adjusted odds ratio [OR] 0.80; 95% confidence interval [CI], 0.74-0.88; p < 0.001) despite similar predicted in-hospital mortality (1.39 vs. 1.37%; p = 0.17) after accounting for PCI indications and comorbidities. These data suggest that public reporting may lead to better outcomes after PCI by possible mechanisms such as incentivized improvements in operator skill set, increased use of referrals to operators with more expertise for high-risk and complex patients, and improved post-PCI care and medication use.⁸

Unintended Consequences of Public Reporting

Despite potential benefit, public reporting may have unintended consequences. Most significantly, reporting may discourage operators from performing PCI in the most critically ill patients with indications for intervention. These patients have high mortality rates regardless of PCI but are also the most likely to benefit from revascularization.⁹ Joynt et al.¹⁰ showed that use of PCI in patients with acute myocardial infarction (AMI) was lower in states with public reporting compared with nonreporting states (unadjusted rates of 37.7 and 42.7%, respectively; adjusted OR 0.82; 95% CI, 0.71-0.93; p = 0.003). This study also found that the greatest differences in PCI utilization were in patients with the most critical presentations: ST-segment elevation myocardial infarction, cardiogenic shock, and cardiac arrest. Furthermore, rates of PCI use in patients with AMI in Massachusetts prior to state-wide implementation of public reporting in 2005 were no different than in nonreporting states, whereas PCI utilization after 2005 was significantly lower than in nonreporting states. Waldo et al.¹¹ similarly showed significantly lower rates of PCI utilization as well as higher rates of in-hospital mortality for patients with AMI in reporting states. This increased risk of mortality was driven by patients with AMI who did not receive PCI (adjusted OR 1.30; 95% CI, 1.13-1.50), which more than offset the benefit of lower in-hospital mortality in patients who did receive PCI (adjusted OR 0.71; 95% CI, 0.62-0.83) in reporting states. These findings suggest that reporting may have contributed to worse outcomes for patients due to withholding of potentially life-saving interventions.

High-Risk Patient Populations in Public Reporting

Though evidence remains limited, these existing data suggest that public reporting may impose a tradeoff between improved outcomes for patients who undergo PCI and worse outcomes for the most critical cardiac patients who are not offered PCI due to high expected mortality rates. It has also been acknowledged that mortality in the most critical patients who undergo PCI is driven primarily by factors unrelated to the procedure itself and, therefore, may not accurately reflect operator competence.¹² Due to these concerns, New York state excluded patients with cardiogenic shock and hypoxic encephalopathy from publically reported PCI outcomes beginning in 2006.¹³ The American Heart Association has also released a consensus statement in 2013 calling for the exclusion of out-of-hospital cardiac arrest patients from public reporting.¹⁴ McCabe et al.¹⁵ later showed that operators in New York were 28% more likely to perform PCI on patients with AMI and cardiogenic shock after the policy change in 2006, compared with a significantly lower 9% increase seen in comparator nonreporting states over the same time period. Risk-adjusted in-hospital mortality for patients with AMI and shock in New York also decreased significantly faster after the policy change (relative risk [RR] 0.76; 95% CI, 0.72-0.81; p < 0.001) compared with nonreporting states (RR 0.91; 95% CI. 0.87-0.94; p < 0.001; interaction p < 0.001). These findings support the idea that exclusion of the highest-risk patients from public reporting may help address risk aversion by operators while also improving mortality outcomes.

In addition to the concerns associated with risk aversion, there are other limitations of publically reporting PCI outcomes that should be recognized. First, the quality of the data source inevitably affects the measured outcomes. Mortality calculated from risk-adjusted models, for example, are commonly extracted from administrative claims data and death certificates, which are often unvalidated or less accurate than risk-adjusted mortality derived from more extensive clinical registry data sets.^6,12 Second, risk-adjusted outcomes remain subject to confounding by unmeasured variables. As an example, surgical ineligibility is one variable that captures clinical information beyond routinely measured data and is associated with increased in-hospital and long-term mortality in patients with left main or triple vessel disease who undergo PCI, even after adjustment for known risk factors.¹⁶ As noted, outcomes such as 30-day mortality may also be poor measures of PCI quality for an individual operator or hospital. Tertiary care referral centers in particular have previously been identified as negative outliers in PCI performance due to a more complex and higher-risk patient population, rather than the skill set of individual operators.¹⁷ Using outcomes with low incidence such as post-PCI mortality also leads to high variance for low-volume providers and makes any comparisons of performance less reliable and more prone to random chance occurrences.¹⁸ Lastly, publically reported PCI outcomes currently do not include positive results such as successful revascularization of complex anatomy, which may better reflect operator proficiency.

Reshaping the Future of PCI Public Reporting

It is clear that pathways to improved reporting of PCI quality are needed. The first obvious step is further engagement by cardiologists. Given our direct role in PCI care as well as our management of the subsequent outcomes, we are the ones best equipped to provide feedback and recommendations on quality metrics used by patients, insurers, administrators, and policymakers with less medical expertise. Next, excluding certain high-risk patients, such as those with cardiac arrest or shock, from public reporting will likely help mitigate operator risk aversion and may improve outcomes, as was demonstrated in New York. Reporting disease-based outcomes such as for myocardial infarction rather than PCI-based outcomes may also help reduce risk aversion while better accounting for other variables in care quality such as medication use. Disease-based reporting would also provide a more thorough measure of quality by incorporating outcomes for patients who do not undergo PCI. Outcomes should also include variables that may be more reflective of PCI quality than mortality, such as improvement in angina symptoms or rates of target lesion revascularization.⁶ Ensuring data quality will continue to be paramount and will involve more thorough data collection as well as improved methods of risk modeling. Finally, we will need to perform ongoing research to help us evaluate the effectiveness and implications of reporting in such a dynamic healthcare environment.

Despite limitations, public reporting of PCI outcomes remains founded on the principles of transparency and accountability that we should seek to uphold as responsible physicians concerned for the well-being of our patients. The movement toward transparency is unlikely to be reversed in the near future. Instead of debating whether PCI outcomes should be made public, we should instead focus our efforts on improving current models of reporting while shaping those to come.

References

1. Dehmer GJ, Drozda JP Jr, Brindis RG, et al. Public reporting of clinical quality data: an update for cardiovascular specialists. J Am Coll Cardiol 2014;63:1239-45.
2. Dziuban SW Jr, McIlduff JB, Miller SJ, Dal Col RH. How a New York cardiac surgery program uses outcomes data. Ann Thorac Surg 1994;58:1871-6.
3. Apolito RA, Greenberg MA, Menegus MA, et al. Impact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock. Am Heart J 2008;155:267-73.
4. Mass-DAC (Department of Health Care Policy, Harvard Medical School website). 2016. Available at: http://www.massdac.org/index.php/about-us/history. Accessed 09/27/2016.
5. Riley RF, Don CW, Aldea GS, et al. Recent Trends in Adherence to Secondary Prevention Guidelines for Patients Undergoing Coronary Revascularization in Washington State: An Analysis of the Clinical Outcomes Assessment Program (COAP) Registry. J Am Heart Assoc 2012;1:e002733.
6. Wasfy JH, Borden WB, Secemsky EA, McCabe JM, Yeh RW. Public reporting in cardiovascular medicine: accountability, unintended consequences, and promise for improvement. Circulation 2015;131:1518-27.
7. Chernew ME, Mechanic RE, Landon BE, Safran DG. Private-payer innovation in Massachusetts: the 'alternative quality contract'. Health Aff (Millwood) 2011;30:51-61.
8. Cavender MA, Joynt KE, Parzynski CS, et al. State mandated public reporting and outcomes of percutaneous coronary intervention in the United States. Am J Cardiol 2015;115:1494-501.
9. Resnic FS, Welt FG. The public health hazards of risk avoidance associated with public reporting of risk-adjusted outcomes in coronary intervention. J Am Coll Cardiol 2009;53:825-30.
10. Joynt KE, Blumenthal DM, Orav EJ, Resnic FS, Jha AK. Association of public reporting for percutaneous coronary intervention with utilization and outcomes among Medicare beneficiaries with acute myocardial infarction. JAMA 2012;308:1460-8.
11. Waldo SW, McCabe JM, O'Brien C, Kennedy KF, Joynt KE, Yeh RW. Association between public reporting of outcomes with procedural management and mortality for patients with acute myocardial infarction. J Am Coll Cardiol 2015;65:1119-26.
12. Aggarwal B, Ellis SG, Lincoff AM, et al. Cause of death within 30 days of percutaneous coronary intervention in an era of mandatory outcome reporting. J Am Coll Cardiol 2013;62:409-15.
13. Berger PB. Response to a Differing Perspective: The Real Issues Related to Public Reporting Around Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2016;9:513-5.
14. Peberdy MA, Donnino MW, Callaway CW, et al. Impact of percutaneous coronary intervention performance reporting on cardiac resuscitation centers: a scientific statement from the American Heart Association. Circulation 2013;128:762-73.
15. McCabe JM, Waldo SW, Kennedy KF, Yeh RW. Treatment and Outcomes of Acute Myocardial Infarction Complicated by Shock After Public Reporting Policy Changes in New York. JAMA Cardiol 2016;1:648-54.
16. Waldo SW, Secemsky EA, O'Brien C, et al. Surgical ineligibility and mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention. Circulation 2014;130:2295-301.
17. McCabe JM, Resnic FS. Strengthening public reporting and maintaining access to care. Circ Cardiovasc Qual Outcomes 2014;7:793-6.
18. Paddock SM. Statistical benchmarks for health care provider performance assessment: a comparison of standard approaches to a hierarchical Bayesian histogram-based method. Health Serv Res 2014;49:1056-73.

Keywords: Acute Coronary Syndrome, Comorbidity, Coronary Artery Bypass, Hospital Mortality, Hypoxia, Brain, Myocardial Infarction, Percutaneous Coronary Intervention, Registries, Risk Factors, Shock, Cardiogenic, Social Responsibility

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