The Good, the Bad, and the Ugly: PCI Public Reporting Needs Fine-tuning, Says SCAI

While maintaining support for the concept of public reporting, the Society for Cardiovascular Angiography and Interventions (SCAI) has presented its stance in a revised position statement on how it can be done to minimize the risk of unintended negative consequences and ensure that the information on PCI outcomes released provides an accurate picture of the quality of care delivered by hospitals and physicians.

Changes are needed based on lessons learned in recent years from states that have already begun publicly reporting data, according to Lloyd Klein, MD (Rush Medical College, Chicago, IL), lead author of the statement, which revises a prior 2011 document.

“We think it’s still a good idea that there be public reporting, but what we’re looking for is for NCDR [the National Cardiovascular Data Registry] and the various state registries to collect a different kind of data than what they’ve been collecting up until now that more accurately reflects how doctors make decisions about who they choose to do interventions on, in order to make the whole public reporting process fairer and allow a better comparison to be made in terms of quality,” he told TCTMD. “I think that’s the key message.”

Klein said that there is “great skepticism” in the cardiology community about whether the current approach to public reporting is the right one and that “we thought that it was necessary to actually deal with some of that in a direct, upfront way” with the revised statement. The document was published online October 18, 2016, ahead of print in Catheterization and Cardiovascular Interventions.

Addressing Risk Aversion

A major concern with releasing PCI outcomes data as it’s done currently, Klein said, is the potential for the unintended consequence of risk-averse behavior, whereby physicians are hesitant to take a high-risk patient who might benefit from a procedure to the cath lab for fear of being unfairly judged if that patient dies.

Klein and his co-authors cite several studies to show that this has occurred in states with public reporting requirements. One analysis showed that in New York, which releases PCI outcomes data to the public, fewer high-risk patients underwent a procedure when compared with Michigan, which does not have public reporting. And another revealed that patients treated for acute MI in states with versus without public reporting were less likely to undergo PCI, and—among those who did not receive an intervention—more likely to die in the hospital.

The authors also point to surveys in which most interventional cardiologists agree that public reporting has had an effect on their decisions about who should go to the cath lab.

Can Models Accurately Reflect Quality?

There are also concerns about the types of information available in the databases from which publicly reported information is derived and about statistical risk adjustment, Klein said.

“Doctors feel, and I think rationally so, that the current systems don’t really capture everything” in terms of the factors that go into whether a patient is treated, Klein said. In particular, he noted, information on whether a patient has been turned down for CABG before undergoing PCI is not captured.

“As an unmeasured confounder, surgical turndown status may be so significant that it might partly explain the apparently higher mortality observed with PCI compared with CABG in comparative outcome studies,” he and his co-authors explain in the statement.

Questions also arise about whether statistical models can adequately adjust for differences in risk to provide a fair comparison between hospitals and operators. “This could result in some excellent operators and hospitals with apparently higher mortality rates being perceived as having poor quality and outcomes because of a high-risk case mix or referrals to their facility,” the authors say.

One approach proposed for dealing with that problem is to exclude specific high-risk groups from reporting requirements, but that, too, can lead to further issues, Klein said, pointing out that some physicians might try to “game” the system by seeking inappropriate exclusions.

Tweaking the Method

To address the major concerns, the authors lay out several recommendations to improve the process of public reporting. They call for:

• Transitioning from procedure-based to disease-based reporting, so information is available both on patients undergoing PCI and those not undergoing an intervention for a given diagnosis
   
• De-emphasizing risk-adjusted mortality as the primary metric
   
• Avoiding the ranking of programs based on risk-adjusted mortality

• Excluding patients with out-of-hospital cardiac arrest and those with preexisting do-not-resuscitate orders from public reports
   
• Reporting of hospital-level risk-adjusted mortality both with and without specific high-risk patient groups included
   
• Eliminating reporting of operator-specific mortality rates
   
• Including other metrics beyond risk-adjusted mortality, such as the proportion of “rarely appropriate” indications; the occurrence of contrast-induced nephropathy, bleeding and vascular complications, and repeat revascularization; case volumes; and patient-reported measures

Klein said the interventional cardiology community has tried to get some of these issues addressed, with NCDR in particular, but “so far it hasn’t worked out all that well.”

“I think it’s up to NCDR to make changes to their algorithm. So far they have been reluctant to do so,” Klein said. “We’re hoping through SCAI and within the interventional council of the [American College of Cardiology] that maybe they’ll hear that. I’m afraid that if they don’t hear it from the people who are their friends—I’m a friend—that there will be negative consequences for the whole interventional community and for our patients.”

The issue takes on greater importance in the context of performance-based reimbursement, Klein noted.

“The great fear that we have is that as we go to a value-based system—MACRA and other forms of reimbursement that are not fee-for-service—exactly how you measure value, exactly what components of outcomes people think that value encompasses, that’s going to determine what kinds of procedures are done and in which patients,” he said.

“So this is about public reporting, but public reporting has become about so much more than just letting people know what the doctors are doing,” he continued. “It’s so much more than quality assessment now, and we thought we needed a new document that tried to get at some of these really substantially new and different ideas about it.”