New York State Public Reporting on PCI Mortality Does Little to Change Behavior

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The success of public reporting on outcomes after coronary artery bypass graft (CABG) surgery has spawned efforts to extend such transparency to other procedures. Yet according to a paper published online January 10, 2012, ahead of print in Circulation: Cardiovascular Quality and Outcomes, reports on mortality in conjunction with nonemergent percutaneous coronary intervention (PCI) do not carry the same weight. Hospitals at the extremes tend to continue performing better or worse than average, while the numbers do little to influence patient or physician behavior.

For the study, Lena M. Chen, MD, MS, of the University of Michigan (Ann Arbor, MI), and colleagues examined publicly available reports from the New York State Department of Health to obtain mortality data from 1998 to 2007. During that time frame, 351 cardiologists performed nonemergent PCI at 48 hospitals with high enough volume to be counted in the reports.

Little Variation, Influence

Risk-adjusted mortality rates—the cardiologist’s or hospital’s expected outcomes had they treated patients with a case mix similar to that of New York State as a whole—ranged from 0.35% at the best-performing hospitals to 1.03% at the worst-performing hospitals, depending on the year. Risk-adjusted mortality rates were threefold to eightfold higher for the poor performers. Most hospitals, however, fell somewhere in the middle.

Hospital performance at the time of each report could be used to predict whether particular centers would do well in the future. Patients who picked a hospital that did better than average in prior years had the lowest risk-adjusted mortality after reports were made public—0.47%, compared with 0.61% or 0.72% for those performing as well as or worse than expected (P = 0.02).

Yet the public reports had no effect on patients’ choice of cardiologist or hospital. Nor did their content appear to affect whether interventionalists stayed in the profession. For example, 7% of cardiologists in the worst-performing quartile for 2001 to 2003 chose to leave the field after the report was released in 2005. Yet 6% of those in the best-performing quartile also left practice.

A Departure from CABG

“[P]rior studies have shown that public reports on CABG accurately forecast who will be the best-performing providers after report release, are associated with improved mortality, and likely to encourage poor-quality surgeons to leave practice,” the authors write.

But there are several reasons why PCI reporting might be different, they note. For one, PCI has lower mortality rates than CABG, making it more difficult to tease out differences and providing less impetus for physicians to be discouraged. Referral patterns for the 2 procedures could also come into play. “For CABG, cardiologists, who are themselves subject to public reporting for cardiovascular procedures (ie, PCI), refer patients to surgeons,” they explain. “For PCI, cardiologists self-refer or receive referrals from primary care physicians.”

That being said, Dr. Chen told TCTMD in an e-mail communication that the current results “are consistent with prior studies showing that patients . . . often ignore publicly reported quality performance reports when choosing hospitals, doctors, or health plans. Patients may not see the data in a timely manner, or have difficulty interpreting it, or be reluctant to rely on it over the advice of friends and providers.” The researchers could not determine specifically why PCI patients did not seem to be making choices based on public reports, she noted, pointing out that one factor may be the relatively similar mortality risks across the board in New York State.

‘Immense Opportunity’ for Optimizing Care

In a telephone interview with TCTMD, Harlan M. Krumholz, MD, SM, of the Yale School of Medicine (New Haven, CT), echoed this point—that PCI-related mortality was consistently low among New York hospitals. “People can go to any one of a large number of hospitals and be assured they’re getting the same care, which means they don’t have to shop around,” he said.

Dr. Krumholz noted that the findings also offer an “immense opportunity” to improve the overall quality of care. “[The study] does suggest that there are some hospitals that have developed approaches that allow them to do this procedure more safely,” he said. “That opens up a great research question of, Can we learn from the top performers?”

“I hope it will be in the spirit of not trying to tell people who to avoid but in trying to raise the level of performance for everyone,” he commented. “Part of the therapeutic relationship is trusting the person caring for you. But I do think that administrators, policy makers, and, increasingly, clinicians will be looking at these numbers.”

Despite its lack of influence on patient behavior, Dr. Chen agreed that “public reporting on PCI may still be valuable, as it has other purposes, including the motivation of quality improvement efforts.” The current study did not assess whether or not reporting was associated with improved outcome, she added.

 

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Source:
Chen LM, Orav EJ, Epstein AM. Public reporting on risk-adjusted mortality after percutaneous coronary interventions in New York State: Forecasting ability and impact on market share and physicians’ decisions to discontinue practice. Circ Cardiovasc Qual Outcomes. 2012;Epub ahead of print.

 

 

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