Shock in Public Reporting of PCI Risk-Adjusted Mortality
What is the impact of including or excluding shock patients in public reporting of percutaneous coronary intervention (PCI) risk-adjusted mortality?
The authors used New York State’s PCI registry to compare hospital and physician risk-adjusted mortality rates and outliers based on statistical models that included refractory shock patients and excluded both refractory shock and other shock patients.
There was excellent correlation between the public report model and each of the other two models (0.92 for hospital risk-adjusted rates and 0.99 for all physician risk-adjusted rates, p < 0.0001). There were 11 physicians with lower than expected mortality rates (low outliers) and 41 physicians with higher than expected mortality rates (high outliers) across the three time periods in the public report, compared with 10 low outliers and 40 high outliers if all shock patients had been excluded. There was considerable overlap among outliers identified by the three models.
Inclusion or exclusion of shock did not materially change the risk-adjusted mortality rates for physicians and hospitals.
There have been concerns that public reporting of PCI outcomes has been associated with risk aversion and a lower use of PCI in patients with shock. The authors suggest that inclusion or exclusion of shock does not significantly impact the risk-adjusted mortality for most patients. The challenge with this analysis is that it comes from a state with public reporting and does not take into account patients who were denied PCI on account of being extremely high risk. It would be interesting to assess if the same findings can be replicated in states without mandated public reporting.
Keywords: Mortality, Percutaneous Coronary Intervention, Risk Assessment, Outcome Assessment (Health Care), Shock, Cardiogenic
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