Pitfalls Associated with Public Reporting for PCI Outcomes
Public Reporting Percutaneous Coronary Intervention (PCI) Outcomes
Risk-adjusted mortality reporting (RAMR) following coronary revascularization is one of the most commonly used standards for measuring intervention quality.
RAMR has been useful in the identification of hospital outliers, spurring improvement of quality care. Although RAMR can help provide insight into 30-day mortality outcomes following PCI, it may not be a reliable determinant of procedural quality. The 30-day survival after PCI is impacted by other factors related to patient-specific characteristics.1 The adjustment for patient risk factors can be useful for adjusting patient and procedure selection variability; however, there’s currently no widely accepted agreement or methodology for risk adjustment.
Limitations Associated with Publicly Reported Data in Cardiology
There’s concern that the limitations associated with public reporting of RAMR post-PCI might create a faulty reputation for hospitals and physicians, likely hindering optimal physician selection among patients. Authors of a recent paper published in JACC: Cardiovascular Interventions investigated the accuracy of various risk models in assessing mortality in high-risk patients receiving PCI. Also, the authors examined the far-reaching implications associated with using 30-day mortality as an interventional quality metric.2
According to the literature, the higher mortality risk associated with PCI is not attributed to the intervention itself, but to elevated baseline mortality risk. Patients with cardiogenic shock and cardiac arrest patients who have been resuscitated represent a subgroup of PCI-treated patients who experience a particularly high mortality following the procedure. In patients with out-of-hospital cardiac arrest, mortality is up to 50%. When this occurs within the 30-day timeframe, publicly reported data may incorrectly mark higher mortality PCI operators and programs as deficient in quality.
Covariates containing nontraditional factors associated with high-risk patients should be incorporated into overall risk adjustment. Additionally, authors of this paper suggest outcomes for high-risk patients may not be relevant for assisting the public in choosing healthcare providers in the setting of acute critical care such as STEMI and cardiogenic shock. Available RAMR data is suggested to be considered for public reporting, and high-risk patients’ data may not be as highly relevant or helpful for patients intent on choosing their own healthcare providers.
- Valle JA, Smith DE, Booher AM, Menees DS, Gurm HS. Cause and circumstance of in-hospital mortality among patients undergoing contemporary percutaneous coronary intervention: a root-cause analysis. Circ Cardiovasc Qual Outcomes. 2012;5(2):229-235.
- Gupta A, Yeh RW, Tamis-Holland JE, et al. Implications of Public Reporting of Risk-Adjusted Mortality Following Percutaneous Coronary Intervention: Misperceptions and Potential Consequences for High-Risk Patients Including Nonsurgical Patients. JACC Cardiovasc Interv. 2016;9(20):2077-2085.