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

Abstract

Context Public reporting of patient outcomes is an important tool to improve quality of care, but some observers worry that such efforts will lead clinicians to avoid high-risk patients. Objective To determine whether public reporting for percutaneous coronary intervention (PCI) is associated with lower rates of PCI for patients with acute myocardial infarction (MI) or with higher mortality rates in this population. Design, Setting, and Patients Retrospective observational study conducted using data from fee-for-service Medicare patients (49,660 from reporting states and 48,142 from nonreporting states) admitted with acute Ml to US acute care hospitals between 2002 and 2010. Logistic regression was used to compare PCI and mortality rates between reporting states (New York, Massachusetts, and Pennsylvania) and regional nonreporting states (Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland, and Delaware). Changes in PCI rates over time in Massachusetts compared with nonreporting states were also examined. Main Outcome Measures Risk-adjusted PCI and mortality rates. Results In 2010, 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%, respectively; risk-adjusted odds ratio [OR], 0.82, 95% CI, 0.71–0.93, P=.003). Differences were greatest among the 6708 patients with ST-segment elevation Ml (61.8% vs 68.0%; OR, 0.73 [95% CI, 0.59–0.89]; P=.002) and the 2194 patients with cardiogenic shock or cardiac arrest (41.5% vs 46.7%, OR 0.79 [0.64, 0.98], P=.030). In Massachusetts, odds of PCI for acute Ml were comparable with odds in nonreporting states prior to public reporting (40.6% versus 41.8%, OR 1.00 [0.71, 1.41]). However, after implementation of public reporting, odds of undergoing PCI in Massachusetts decreased compared with nonreporting states (41.1% versus 45.6%, OR 0.81 [0.47, 1.38], p=.030 for difference in differences). Differences were most pronounced for the 6081 patients with cardiogenic shock or cardiac arrest (pre-reporting, 44.2% versus 36.6%, OR 1.40 [0.85, 2.37] post-reporting, 43.9% versus 44.8%, OR 0.92 [0.38, 2.22], p=.028 for difference in differences). There were no differences in overall mortality among acute MI patients in reporting versus non-reporting states. Conclusions Among Medicare beneficiaries with acute Ml, the use of PCI was lower for patients treated in 3 states with public reporting of PCI outcomes compared with patients treated in 7 regional control states without public reporting. However, there was no difference in overall acute Ml mortality between states with and without public reporting.

Health Policy and Cardiovascular Medicine

“…21 Additionally, states with mandatory PCI reporting were shown to have lower rates of use of PCI for patients with an AMI; this was associated with higher mortality for patients with ST-segment-elevation myocardial infarction, although overall AMI mortality rates were similar to those in nonreporting states. 19 There is some evidence to suggest that public reporting may also influence clinical practice for CABG, particularly for racial and ethnic minorities, although here the data are less consistent. [22][23][24][25] Physician-level public reporting is much less common than hospital-level reporting.…”

“…17 Finally, in terms of state-based programs, initial reports showed lower mortality in reporting states for CABG 18 but more recent work suggested no mortality benefit for PCI. 19 There has also been concern that reporting programs may have the unintended consequence of limiting access to care. Studies have shown a lower propensity to undergo PCI for AMI in New York compared with Michigan (a nonreporting state), 20 particularly in the setting of cardiogenic shock.…”

Hospital Performance on Percutaneous Coronary Intervention Process and Outcomes Measures

“…The past decade has seen a dramatic increase in efforts to measure and report the quality of care delivered to patients undergoing percutaneous coronary intervention (PCI) 1, 2. A number of PCI‐related process measures already exist,3 and there are ongoing efforts both to expand the number of process measures and implement outcomes measures to characterize the quality of care for patients undergoing PCI.…”

Variability in the Use of Invasive Services

“…[26][27][28][29][30] Performance measures have been in place since the 1990s. Many have been process measures such as doorto-balloon times.…”