State Mandated Public Reporting and Outcomes of Percutaneous Coronary Intervention in the United States

Abstract

Public reporting has been proposed as a strategy to improve health care quality. Percutaneous coronary interventions (PCIs) performed in the United States from July 1, 2009, to June 30, 2011, included in the CathPCI Registry were identified (n = 1,340,213). Patient characteristics and predicted and observed in-hospital mortality were compared between patients treated with PCI in states with mandated public reporting (Massachusetts, New York, Pennsylvania) and states without mandated public reporting. Most PCIs occurred in states without mandatory public reporting (88%, n = 1,184,544). Relative to patients treated in nonpublic reporting states, those who underwent PCI in public reporting states had similar predicted in-hospital mortality (1.39% vs 1.37%, p = 0.17) but lower observed in-hospital mortality (1.19% vs 1.41%, adjusted odds ratio [ORadj] 0.80; 95% confidence interval [CI] 0.74, 0.88; p <0.001). In patients for whom outcomes were available at 180 days, the differences in mortality persisted (4.6% vs 5.4%, ORadj 0.85, 95% CI 0.79 to 0.92, p <0.001), whereas there was no difference in myocardial infarction (ORadj 0.97, 95% CI 0.89 to 1.07) or revascularization (ORadj 1.05, 95% CI 0.92 to 1.20). Hospital readmissions were increased at 180 days in patients who underwent PCI in public reporting states (ORadj 1.08, 95% CI 1.03 to 1.12, p = 0.001). In conclusion, patients who underwent PCI in states with mandated public reporting of outcomes had similar predicted risks but significantly lower observed risks of death during hospitalization and in the 6 months after PCI. These findings support considering public reporting as a potential strategy for improving outcomes of patients who underwent PCI although further studies are warranted to delineate the reasons for these differences.

The National Cardiovascular Data Registry Voluntary Public Reporting Program

“…Advocates argue that public reporting enables patients to identify the best physicians and hospitals, simultaneously giving clinicians and health care organizations incentives to improve quality (31). Some studies have shown associations between public reporting and higher quality of care (32,33). Opponents counter that data used in some measures lack adequate clinical granularity to accurately reflect quality or that outcomes reporting may encourage denial of care to the sickest patients who might benefit most from treatment, but are also at highest risk for poor outcomes (34–41).…”

Public Reporting of Percutaneous Coronary Intervention Outcomes

“…However, the better outcomes noted in this procedure-based analysis likely reflect some degree of case selection. 11 Collectively, the evidence to date suggests that public reporting impedes access to potentially life-saving interventions for the critically ill. 3–5,8,9 …”

High-Risk Percutaneous Coronary Intervention in Public Reporting States: the Evidence, Exclusion of Critically Ill Patients, and Implications

“…The latter finding was also observed in an analysis by Cavender et al of the CathPCI national registry – adjusted in-hospital mortality was lower among patients that underwent PCI for acute coronary syndrome in reporting compared with non-reporting states (OR 0.81; 95% CI 0.74–0.89). 6 …”

“…6 It is still unclear whether public reports actually improve care delivery before and after PCI, and if they motivate refinements in operator skillset, likely because the latter is difficult to measure. In the absence of this information, data on PCI outcomes in isolation is challenging to interpret as it is unclear to what extent variations in outcomes reflect true improvements in quality rather than provider risk aversion.…”