Association of Public Reporting for Percutaneous Coronary Intervention With Utilization and Outcomes Among Medicare Beneficiaries With Acute Myocardial Infarction

Study Questions:

What is the impact of public reporting of percutaneous coronary intervention (PCI) results on utilization of PCI for patients with acute myocardial infarction (MI)?

Methods:

The authors compared risk-adjusted PCI and mortality rates using data from fee-for-service Medicare patients (49,660 from reporting states and 48,142 from nonreporting states) admitted with acute MI to US acute care hospitals between 2002 and 2010. Outcomes were compared between reporting states (New York, Massachusetts, and Pennsylvania) and regional nonreporting states (Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland, and Delaware).

Results:

Patients with acute MI were less likely to receive PCI in public reporting states than in nonreporting states (unadjusted rates, 37.7% vs. 42.7%; adjusted odds ratio [OR], 0.82; 95% confidence interval [CI], 0.71-0.93; p = 0.003). This difference was most pronounced among the 6,708 patients with ST-segment elevation MI (61.8% vs. 68.0%; OR, 0.73; 95% CI, 0.59-0.89; p = 0.002), and the 2,194 patients with cardiogenic shock or cardiac arrest (41.5% vs. 46.7%; OR, 0.79; 95% CI, 0.64-0.98; p = 0.03). There were no differences in overall mortality among patients with acute MI in reporting versus nonreporting states. In Massachusetts, there was no difference in use of PCI for acute MI compared with nonreporting states prior to public reporting (40.6% vs. 41.8%; OR, 1.00; 95% CI, 0.71-1.41). After implementation of public reporting, odds of undergoing PCI in Massachusetts decreased compared with nonreporting states (41.1% vs. 45.6%; OR, 0.81; 95% CI, 0.47-1.38; p = 0.03 for difference in differences). Differences were most pronounced for the 6,081 patients with cardiogenic shock or cardiac arrest (p = 0.03 for difference in differences).

Conclusions:

Among Medicare beneficiaries with acute MI, the use of PCI was lower for patients treated in states with public reporting of PCI outcomes compared with patients treated in regional control states without public reporting. There was no difference in overall acute MI mortality between states with and without public reporting.

Perspective:

The clinical impact of public reporting of PCI outcomes remains debatable, and the current and prior studies suggest that it may be associated with risk aversion and a reduction in use of PCI in the sickest patients. At the same time, the overall mortality was not different, and a decline in PCI rates was accompanied by an increase in use of coronary artery bypass grafting. This would suggest that some of the patients might be getting alternative and possibly more appropriate care, or PCI may be being withheld in patients where the procedure may be considered futile. Further, it is likely that physicians in public reporting states are more likely to ensure appropriate coding for comorbidities and acuity of illness, and this is likely to impact the risk-adjustment process. Public reporting of PCI outcomes is set to expand nationally, and more studies like this are needed to assess the impact of such policy on procedure use and outcome.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Pennsylvania, Maryland, Myocardial Infarction, Maine, Connecticut, Delaware, Vermont, Rhode Island, Massachusetts, New Hampshire, Percutaneous Coronary Intervention


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