Changes in Public Reporting and Their Impact on Treatment and Outcomes of Acute Myocardial Infarction
- Public reporting of mortality outcomes for coronary revascularization has resulted in significant risk aversion among PCI operators, potentially reducing patient care quality.
- After excluding refractory cardiogenic patients from publicly reported PCI data, New York operators were more likely to perform high-risk PCI for patients with acute coronary syndrome complicated by cardiogenic shock. This change resulted in a trend toward improved mortality.
Public reporting was originally designed to build public trust and improve care quality; however, there is some speculation that the reporting of treatment outcomes may lead to intervention avoidance, particularly for high-risk patients requiring percutaneous coronary intervention (PCI). This risk avoidance may negatively impact public health by reducing PCIs performed for at-risk patients.
In 2006, the New York State Department of Public Health began excluding refractory cardiogenic shock (CS) patients from public reporting of PCI in an effort to combat risk avoidance.
A study published in JAMA Cardiology examined the effects this policy change had for patients with acute myocardial infarction (AMI) complicated by CS (n=45,977).1 Specifically, the change in rates of coronary revascularization and in-hospital mortality for New York AMI patients (n=11,298) complicated by CS following the exclusion of CS from public reporting were evaluated.
States that do not report risk-adjusted mortality, like California, Michigan, and New Jersey, were used as comparator states. Massachusetts, which includes CS patients in public reporting, was also used in the comparison.
There was an increase in the number of patients who underwent PCI for shock following the policy change (49.2%) of 2006-2012 vs the reference period (44.9%) of 2002-2005. Following exclusion of CS from public reporting, a trend toward decreased incidence of in-hospital mortality was also observed (37.9% in the post-policy period vs 44.7% in the reference period).
In addition to decreased in-hospital mortality, New York also saw an increase in the use of the following procedures (reference period to post-policy period):
- Coronary angiography (63.6% to 67.9%, respectively)
- PCIs (30.5% to 39.7%, respectively)
According to the pooled data, comparison states reported similar increases in the use of the above procedures. CABG use slightly decreased or remained unchanged between both periods and among all states.
Adjustment for presentation risk factors and patient demographics resulted in an observed 28% increase in PCI for AMI patients with CS after the New York policy changes for public reporting. Despite these findings, New York continued to report lower rates of coronary revascularization for AMI patients complicated by CS, potentially reflecting the persistent hesitation among physicians to recommend PCI for high-risk patients.
- McCabe JM, Waldo SW, Kennedy KF, Yeh RW. Treatment and Outcomes of Acute Myocardial Infarction Complicated by Shock After Public Reporting Policy Changes in New York. JAMA Cardiol. 2016;1(6):648-654.