Public Reporting of PCI Mortality: Debate Swirls Around What’s Fair, What’s Ethical

Public reporting of PCI mortality rates occurs in Massachusetts, New York, and Pennsylvania at the moment and is likely to spread to other states. But debate continues about how best to implement such programs without creating an environment in which physicians may be reluctant to treat the highest-risk patients for fear of skewing their mortality stats upward.

Including patients with out-of-hospital cardiac arrest or cardiogenic shock—who have a substantially greater risk of dying compared with others—when tallying PCI mortality rates would lead to such “risk-averse behavior” on the part of physicians or even encourage centers to transfer such patients to other facilities to undergo the procedure, according to Tanveer Rab, MD (Emory University, Atlanta, GA), and Hadley Wilson, MD (Carolinas Medical Center, Charlotte, NC).

“In many cases, PCI is a bystander event, and most of the mortality in this population is due to neurological complications of anoxic brain injury or multiorgan failure despite receiving optimal care and achieving a perfect PCI result,” they write in the March 14, 2016, issue of JACC: Cardiovascular Interventions. Thus, “public reporting of death as a PCI complication in such cases is flawed and fundamentally incorrect and sends the wrong message to the public.”

In their opinion piece, which was endorsed by the American College of Cardiology (ACC) Interventional Council and Board of Governors, they recommend continuing to collect data on all PCI patients but excluding two groups—resuscitated comatose patients after cardiac arrest and patients with cardiogenic shock—from risk-adjusted PCI mortality rates in the National Cardiovascular Data Registry (NCDR) CathPCI Registry.

The exclusion of patients with cardiac arrest from publicly reported PCI outcomes has also been advocated in a scientific statement by the American Heart Association (AHA) and in the 2013 STEMI guidelines from the ACC/AHA.

“We want transparency,” Rab told TCTMD, adding, however, that there is concern that entities like health insurance companies will use skewed data to make decisions about which centers should receive bonuses and which should not. Grouping mortality data from all PCI patients “is not right, or fair, or correct” and could have an adverse effect on patient care, he said.

How to Avoid Risk Avoidance?

A major concern at the center of the public reporting debate is whether risk can be adequately adjusted for when releasing PCI mortality rates. That becomes even more of an issue when looking at the highest-risk patients, like those with cardiac arrest or cardiogenic shock. According to a survey cited by Rab and Wilson, the overwhelming majority of cardiologists in New York State (86%) said that current risk-adjustment methodology was insufficient “to avoid penalizing physicians who perform higher-risk interventions.”

That distrust breeds the potential for risk-avoidance behaviors among physicians who do not want to be punished for performing PCI in a patient who likely would have died regardless of how well the procedure was performed.

In an invited response to Rab and Wilson’s paper, Peter Berger, MD (Northwell Health, Great Neck, NY), notes that the existence of risk-avoidance behaviors influenced the decision of the New York State Cardiac Advisory Committee—of which he is a member—to exclude patients with shock or hypoxic encephalopathy from public reporting in that state. Not all patients with cardiac arrest are excluded, however, because some are promptly resuscitated and do not have neurologic injury or hemodynamic stability.

But even while acknowledging that risk-averse behavior exists and is exacerbated by public reporting, Berger, in an email to TCTMD, took a strong stance against physicians who allow such concerns to affect the way they practice.

“It is unconscionable for a physician to refuse to do a much-needed procedure that has been proven to substantially reduce mortality on a desperately ill patient because of fear of the possible impact on one’s reputation as a result of public reporting,” he said. “And risk adjustment usually does account for the severity of illness; physicians who do such procedures usually benefit from doing so in terms of their risk-adjusted mortality. Lastly, risk-averse behavior amongst proceduralists and surgeons goes on even without public reporting, and ought not be tolerated.”

Such behavior, he writes in his response, “ought to result in sanctions from the hospital at which [physicians] practice, as well as from medical societies and professional boards. And—wait for it—I believe such behavior ought to be publicly reported.”

Education Instills Trust in the System

Robert Yeh, MD (Beth Israel Deaconess Medical Center, Boston, MA), commenting on the papers, told TCTMD that he is “of two minds” about the issue of public reporting.

As someone who leads an outcomes research program and clinical investigations and is interested in quality of care, he sees the positives in improving transparency, including the incentivization of quality improvement and the enhancement of patients’ and physicians’ understanding of outcomes. “I think those are good things in general,” said Yeh, who is director of the Smith Center for Outcomes Research in Cardiology at Beth Israel.

On the other hand, as a practicing interventional cardiologist, Yeh understands the challenges of trying to apply risk-adjustment methodology to patients. “And when those limitations . . . and the threat of public reporting start entering the minds of clinicians, it does create a scenario where they often may be incentivized in some way, shape, or form to not provide the optimal care for the patient,” he said.

Unlike New York, Massachusetts only excludes “a small handful of very exceptional cases”—but not patients with shock or cardiac arrest—from public reporting of PCI outcomes, Yeh said. Instead, the state has refined its risk-adjustment strategy by carefully adjudicating individual cases of patients presenting with coma or cardiogenic shock and incorporating those individual variables into the adjustment methodology. That strategy has seemingly improved confidence in the risk-adjustment methodology, as illustrated by increasing rates of PCI for patients with cardiogenic shock, he noted.

“I think some level of making sure that we either exclude or precisely adjust for . . . certain types of patient illness, like cardiogenic shock or coma presentation in cardiac arrest, is warranted,” he said.

Yeh acknowledged that there is a lot of distrust of risk-adjustment methodology on the part of interventional cardiologists. “But I would say that if there are 85% of interventional cardiologists [who] don’t trust this risk-adjustment methodology [then] 95% of them don't actually understand it,” he said.

Therefore, the first step in establishing trust in the system is education about what goes into it, he said. Next, the methodology must be shown to be clinically credible by involving interventional cardiologists—and not just outsiders—in the process. “That engagement of the actual physicians who are involved in these procedures, I think, is really critical for there to be buy-in,” Yeh said.

Sources: 
1. Rab T, Wilson H. Public reporting of mortality after PCI in cardiac arrest and cardiogenic shock: an opinion from the Interventional Council and the Board of Governors of the America College of Cardiology. J Am Coll Cardiol Intv. 2016;9:496-498.
2. Berger PB. Response to a differing perspective: the real issues related to public reporting around percutaneous coronary intervention. J Am Coll Cardiol Intv. 2016;9:513-515.

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