Study findings indicate that an increased scrutiny of surgical outcomes has contributed to an approximately 30% decline in valve surgeries for infective endocarditis, regardless of patients’ injection drug use status — an “unintended consequence” of implementing public reporting of outcomes for aortic valve surgery, researchers said.
“There has been an increase in the incidence of injection drug use-associated infective endocarditis (IDU-IE) disease due to the opioid epidemic, and valve surgery is frequently indicated in many of these patients,” said Infectious Disease News Editorial Board Member Raghavendra Tirupathi, MD, FACP, medical director of Keystone Infectious Diseases/HIV, chair of infection prevention at Summit Health and clinical assistant professor of medicine at Penn State University School of Medicine.
“There is hesitancy among surgeons occasionally to proceed with valve replacement in patients who inject drugs due to concern for continued drug use and hence, probable increased probability of poor postsurgical outcomes in this subgroup,” Tirupathi, who was not involved in the study, added.
For the study, Simeon D. Kimmel, MD, MA, research fellow in infectious disease and addiction medicine at Boston Medical Center, and colleagues used data collected between January 2010 and September 2015 from the National Inpatient Sample — a representative sample of U.S. inpatient hospitalizations. Their analysis included adults aged 18 to 65 years who had an endocarditis diagnosis with or without associated injection drug use.
“In 2013, the Society of Thoracic Surgery began publicly reporting the outcomes of aortic valve surgeries for individual surgeons and hospitals,” Kimmel told Infectious Disease News. “Because endocarditis has greater mortality risk than other kinds of valve surgeries, we wanted to know if surgeons would avoid performing valve replacement surgery for patients with endocarditis following the implementation of this program.”
The researchers identified 7,322 hospitalizations for IDU-IE and 23,997 for non-IDU-IE. According to the study, this represents 36,452 national IDU-IE admissions and 119,316 non-IDU-IE admissions.
The odds of valve replacement decreased 4% per quarter (OR = 0.96; 95% CI, 0.93-0.99) after public reporting was implemented, with no difference observed by IDU status. Kimmel explained that 2 years after public reporting began, it was 30% less likely that people with IDU-IE and non-IDU-IE would receive valve replacement surgery.
“It appears that surgeons are operating less because they are worried about bad outcomes from taking on high-risk cases,” he said. “Public reporting was intended to promote transparency and improve quality of care, but may have had the unintended consequence of reducing access to valve replacement surgery, a potentially lifesaving procedures for people with endocarditis. Removing endocarditis from reporting measures or risk adjusting more powerfully for these patients may mitigate these unintended consequences.”
Public reporting also impacted mortality rates. After implementation, the odds of inpatient death decreased by 2% per quarter among individuals with IDU-IE and non-IDU-IE (OR = 0.98; 95% CI, 0.97–0.99).
However, Tirupathi noted that the study is “limited” because long-term mortality associated with reduced access to surgery was not measured.
“Further studies should assess postdischarge and long-term mortality rates. While public reporting may have improved the overall aortic valve surgery quality, the measures may have decreased access to valve surgery for endocarditis patients,” he said.
Kimmel and colleagues recommended that future studies focus on post-discharge mortality rates to better understand how reduced valve surgery impact mortality overall. Kimmel noted that ID clinicians do not decide if a patient with endocarditis undergoes surgery, but there are still ways they can improve care.
“ID clinicians can advise surgeons and advocate for their patients to receive guideline-concordant care,” Kimmel said. “Multidisciplinary endocarditis working groups that include ID physicians, cardiologists, cardiac surgeons and, if relevant, addiction medicine physicians, can provide a structured forum to facilitate these conversations. Additionally, ID physicians have an opportunity to improve care for their patients with injection drug associated endocarditis by becoming wavered buprenorphine prescribers and offering this lifesaving, evidence-based treatment starting in the hospital.” – by Marley Ghizzone
Kimmel SD, et al. Clin Infect Dis. 2019;doi:10.1093/cid/ciz834.
Disclosures: Kimmel reports being supported by various fellowships and grants. Please see the study for all other authors’ relevant financial disclosures. Tirupathi reports no relevant financial disclosures.