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Public Reporting and Outcomes in Acute MI | Journal Scan
Study Questions:
What is the association between public reporting with procedural management and outcomes among patients with acute myocardial infarction (AMI)?
Methods:
The authors used the Nationwide Inpatient Sample, and identified all patients with a primary diagnosis of AMI in states with public reporting (Massachusetts and New York) and regionally comparable states without public reporting (Connecticut, Maine, Maryland, New Hampshire, Rhode Island, and Vermont) between 2005 and 2011. Procedural management and in-hospital outcomes were stratified by public reporting. The investigators evaluated the association between public reporting and in-hospital mortality using logistical regression models adjusted for demographic and clinical characteristics.
Results:
The authors reported that among 84,121 patients hospitalized with AMI, 57,629 (69%) underwent treatment in a public reporting state. After multivariable adjustment, percutaneous revascularization was performed less often in public reporting states compared with nonreporting states (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.67-0.96), especially among older patients (OR, 0.75; 95% CI, 0.62-0.91), those with Medicare insurance (OR, 0.75; 95% CI, 0.62-0.91), and those presenting with ST-segment elevation myocardial infarction (OR, 0.63; 95% CI, 0.56-0.71) or concomitant cardiac arrest or cardiogenic shock (OR, 0.58; 95% CI, 0.47-0.70). Overall, patients with AMI in public reporting states had higher adjusted in-hospital mortality (OR, 1.21; 95% CI, 1.06-1.37), compared with nonreporting states. This was predominately observed in patients who did not receive percutaneous revascularization in public reporting states (OR, 1.30; 95% CI, 1.13-1.50), while those undergoing the procedure had lower mortality (OR, 0.71; 95% CI, 0.62-0.83).
Conclusions:
The authors concluded that public reporting is associated with reduced percutaneous revascularization and increased in-hospital mortality, particularly among patients not selected for percutaneous coronary intervention (PCI).
Perspective:
This study evaluated the association between state-mandated public reporting with procedural management and in-hospital outcomes among patients presenting with a myocardial infarction and reports that patients treated in a public reporting state are less likely to undergo PCI, particularly when they have high-risk features: older age, cardiogenic shock, cardiac arrest, or a STEMI. The data imply that public reporting may improve PCI-related outcomes, but may also have the unintended consequence of increasing risk aversion to the detriment of overall outcomes for patients with MI. It should be noted that analysis performed in the present study is only able to evaluate the association between public reporting and outcomes and cannot prove causality. Further studies in other data sets, particularly clinical databases such as the American College of Cardiology National Cardiovascular Data Registry (NCDR), need to be performed to validate these observations.
Keywords: Acute Coronary Syndrome, Myocardial Revascularization, Percutaneous Coronary Intervention, Hospital Mortality, Inpatients, Medicare, Myocardial Infarction, Shock, Cardiogenic, Risk Factors, Heart Arrest
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