PCI mortality rates unaffected by inclusion of patients with cardiogenic shock
The inclusion of patients with cardiogenic shock in public reporting did not significantly affect risk-adjusted mortality rates by hospital or physician after PCI, according to recently published data.
Currently, public reporting of risk-adjusted PCI mortality rates excludes patients with cardiogenic refractory shock and a subset of patients with anoxic brain injury. Some physicians, however, question whether these exclusions should also include patients with nonrefractory shock.
Using data from the New York Percutaneous Coronary Interventions Reporting System, the researchers compared the current model for public reporting with a model that included all patients undergoing PCI, including those with refractory shock, and another that excluded patients with refractory and nonrefractory shock. Patients with anoxic brain injury were excluded from all analyses.
Data from 2009 to 2013 were used to evaluate physician risk-adjusted mortality rates and from 2011 to 2013 to evaluate hospital risk-adjusted mortality rates.
Correlations between the currently used model and the two alternative models were high for physician risk-adjusted mortality rates (0.99; P < .0001) and hospital risk-adjusted mortality rates (0.92; P < .0001). The number of outliers, defined as hospitals or physicians with lower- or higher-than-expected mortality rates, was also similar, with significant overlap among outliers across the three models. However, 10% to 15% of physicians deemed to be outliers in one of the two exclusion models were not outliers in the other model.
“The study’s results support the current New York State PCI public reporting policy in the aggregate: The two alternatives studied identify a very similar number of outlier physicians and institutions when compared with the existing reporting policy,” Frederic S. Resnic, MD, MSc, and Arjun Majithia, MD, both from the department of cardiovascular medicine at Lahey Hospital and Medical Center in Burlington, Massachusetts, wrote in an accompanying editorial. “However, a different picture emerges when viewed through the perspective of an individual PCI operator. From this vantage, there should be significant concerns regarding which specific operators are identified using the alternative analysis policies.”
Moreover, Resnic and Majithia noted that many interventional cardiologists are concerned about being misidentified as negative outliers, which can significantly affect their professional reputations and careers. These different models based on the inclusion or exclusion of patients with cardiogenic shock “will be unlikely to assuage concerns regarding the imprecision of contemporary risk-adjustment approaches used for public reporting.”
In light of these data, Resnic and Majithia suggested adding other quality measures, such as access to care, procedural appropriateness and evaluation of condition-specific outcomes, to public reports.
“We also advocate for the continued collection and review of all PCI cases, but excluding from the publicly released reports extraordinarily high-risk emergent patients, including those experiencing out-of-hospital cardiac arrest and all patients presenting with cardiogenic shock before PCI,” they wrote. – by Melissa Foster
Disclosure: Two researchers report financial ties with Abbott Vascular, AstraZeneca, Capicor, Merck and Stentys. Resnic and Majithia report no relevant financial disclosures.