How PCI Mortality Is Publicly Reported Requires Reworking, ACC’s Interventional Council Says

Risk-adjusted mortality is the primary metric included in publicly reported PCI outcomes data, but there is a widespread belief within the interventional cardiology community that changes are needed to improve the quality and fairness of that information. The Society for Cardiovascular Angiography and Interventions (SCAI) recently weighed in on the issue. Now, the Interventional Council of the American College of Cardiology (ACC) has suggested some solutions.

There has been a concern that current methods for risk adjustment cannot fully account for differences across centers in case selection and case mix and that taking high-risk patients—such as those with cardiac arrest or cardiogenic shock or those turned down for surgery—may unfairly “ding” hospitals and operators with an elevated mortality rate, according to Anuj Gupta, MD (University of Maryland School of Medicine, Baltimore), lead author of the viewpoint in the October 24, 2016, issue of JACC: Cardiovascular Interventions.

That can have consequences in terms of receiving reimbursement from insurance companies and may lead to healthcare providers shying away from taking such patients, who often have the most to gain from intervention, to the cath lab, Gupta told TCTMD.

“There is this problem of public reporting of risk-adjusted mortality, particularly when the mortality that often happens in the cath lab has nothing to do with the procedural success but with the underlying illness of the patients,” he said, noting that many of the factors indicative of that underlying risk are not currently being captured in the databases used for risk adjustment.

“There are solutions, none of which are perfect, some of which are expensive, that might mitigate some of that concern,” Gupta said.

Improving the Metric

One potential solution proposed by the Interventional Council is to collect additional variables—reasons a patient has been turned down for surgery, for example—that can be used for risk adjustment to account for high-risk patients. “The most recent proposed update to the data collection form within the CathPCI Registry contains several elements specifically designed to implement this approach,” Gupta et al write.

However, they add, “When adjustment is applied to procedural-based registries, rather than disease-based registries, even the most accurate forms of procedural risk adjustment cannot take into account the clinical consequences of risk-avoidance behaviors (or cases that never enter the procedural database because they are simply not performed).”

Because a perfect risk model does not exist, another solution is to leave specific high-risk patient groups out of public reports of PCI outcomes, Gupta said, adding, though, that that can introduce additional problems. Much of the mortality following PCI is seen in these patients, with very few deaths in those undergoing elective or standard urgent procedures. Thus, Gupta explained, “if you take out the high-risk patients, you start having equal [mortality] numbers across the board and then the risk-adjusted mortality rate may not be a meaningful number at all.”

Yet another option to ease concerns about the accuracy of risk-adjusted mortality is to employ external peer review to assess which cases should be considered extreme risk, a strategy used in Massachusetts.

“Although labor-intensive and costly, this allows the more detailed assessment to ensure the accurate assessment of patient risk and the exclusion of selected cases deemed exceptional on the basis of predefined criteria,” the authors write.

Other suggestions for improving the disclosure of PCI outcomes include reporting process-oriented rather than outcomes measures, deemphasizing risk-adjusted mortality as a metric, and focusing on disease-based rather than procedural outcomes.

Until such changes can be implemented to improve risk adjustment models, “only data on [risk-adjusted mortality] for usual-risk patients should be considered for public reporting; the outcomes reported for high-risk patients would not generally be relevant to the public’s need when selecting providers and hospitals and therefore need not be available for the public to scrutinize,” the authors say.

“Either high-risk patients should be excluded from the metric used to report overall outcomes to the public, or registry agencies should institute a process to allow external peer review of all mortality cases prior to potential public reporting, excluding cases if the deaths that occur are clearly unrelated to the PCI procedure or hospital quality of care,” they conclude.

Note: Viewpoint co-author Ajay Kirtane, MD (NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY), is a faculty member of the Cardiovascular Research Foundation, the publisher of TCTMD.