Time and Money: PCI Public Reporting Requirements Take Their Toll

NEW ORLEANS, LA—There are substantial costs to participating in a statewide public reporting program for PCI outcomes, not only in terms of dollars but also in person hours and perceived physician burden, according to the results of a new study.

In Massachusetts, the median estimated annual cost of participating in the mandatory public reporting program ranges from $100,000 to $200,000 each year, and the median time spent by interventional cardiologists to meet the requirements ranges from 5 to 10 hours per week. And although the public reporting initiative is intended to improve care and provide patients with information, most physicians included in the study felt the potential benefits of PCI public reporting don’t outweigh the administrative and financial burdens, say researchers.

Lead investigator Rishi Wadhera, MD (Beth Israel Deaconess Medical Center, Boston, MA), said that policy initiatives at the state and national level, such as public reporting of PCI outcomes, are frequently deployed with limited evidence showing they are effective. From a research perspective, there has been little attention paid to the burden public reporting requirements impose on physicians and hospitals.  

“As pubic reporting initiatives have been rolled out, there probably has been substantial burden imposed on physicians and institutions with little understanding of exactly what that burden is and how to improve it,” said Wadhera. “We’re in this era of value, and the question should be whether this is a high-value policy or initiative if there is no evidence it’s improving outcomes and there is robust evidence that it may impede access to care for critically ill patients. Now, on top of that, we’re showing these initiatives impose a burden and institutional costs on physicians and institutions.”        

The new data were presented at the American College of Cardiology 2019 Scientific Session last week and published online March 11, 2019, in the Journal of the American College of Cardiology.

Is Public Reporting a High-Value Policy?   

The analysis was based on a survey sent to all 24 cardiac catheterization labs participating in the Massachusetts state public reporting program. In total, 15 labs responded to the survey and these respondents were more likely to be part of a large hospital or teaching institution. Responders also had higher annual PCI volumes than those who did not respond.

The estimated institutional costs of participating in the public reporting program ranged from 0 - $50,000 to more than $300,000. The labs required a median of 1.0 full-time equivalent (FTE) staff to handle the public reporting requirements, although this ranged from 0.5 FTE to 2.75 FTE. The perceived burden of participating in public reporting was relatively high (score of 7, with 1 being least and 10 being the most burdensome). Nearly two-thirds of those surveyed felt the benefits of the public reporting—improvements in quality of care or healthcare transparency—were not offset by the time and money spent.

If you have a deleterious effect with something you think is a good idea, then maybe it’s not such a good idea. Ajay Kirtane

Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), who was not involved in the new analysis but who has studied the tradeoffs on mandatory public reporting for PCI, said his institution has two FTE staff dedicated to data abstraction for reporting PCI outcomes to the New York State department of health. In addition to reporting outcomes as part of the New York program, they also staff FTEs to report data to the American College of Cardiology National Cardiovascular Data Registry (NCDR) to maintain good standing as a "Center of Excellence."

“The costs of this are not small,” he said.

If mandatory state reporting was to go away, physicians and hospitals would still track clinical outcomes to assess their performance in a quantitative manner, said Kirtane. However, one of the major criticisms of mandatory public reporting of PCI outcomes is that it doesn’t completely achieve what it originally set out to achieve.  

“If there were data showing that public reporting of PCI outcomes as currently construed was beneficial and improved outcomes, then I don’t think you’d hear physicians saying this was burdensome,” said Kirtane. “The real challenge is that we know that public reporting is not only shown to not be beneficial, but it’s been linked to risk aversion. In some respects, it’s burdensome because it makes us less effective at doing our jobs. That’s a problem. While many people advocate public reporting a priori on the basis of transparency, it’s really important to assess that if you have a deleterious effect with something you think is a good idea, then maybe it’s not such a good idea.”

Shifting Toward Disease-Based Reporting

Speaking broadly, Wadhera said one of the lessons learned from mandatory public reporting of PCI outcomes is that healthcare policies should be deployed slowly and methodically so that they may be better studied before being adopted by hospitals across the state.

One change that both Kirtane and Wadhera suggested was shifting toward ‘disease-based’ public reporting, where mortality is reported by disease subgroups, such as unstable angina, NSTEMI, STEMI, and even acute MI complicated by cardiogenic shock. Disease-based reporting would be preferable to procedural PCI-centered reporting, which doesn’t capture high-risk patients who were avoided.

“What happens when you focus on procedure-based outcomes is that you don’t see or evaluate what’s happening on the other side of the coin, which is what’s happening with patients who don’t get the procedure,” said Wadhera. “When physicians know you’re reporting outcomes for a disease rather a procedure, there’s no perverse incentive to not perform a procedure in someone you think might not do well. A disease-based approach would encourage physicians to make optimal decisions for patients irrespective of the outcomes being publicly disclosed.”

If physicians were avoiding doing potentially beneficial procedures in high-risk patients, that might be indicated by excellent outcomes in a procedural registry, but less stellar outcomes in a disease-based registry, said Kirtane.