Public reporting and case selection for percutaneous coronary interventions: an analysis from two large multicenter percutaneous coronary intervention databases.

OBJECTIVES The purpose of this research was to determine the potential effect of public reporting on case selection for percutaneous coronary intervention (PCI). BACKGROUND Previous studies have suggested that public reporting of coronary artery bypass graft surgery (CABG) mortality might result in case selection bias and in denial of care to or out migration of high-risk patients. The potential effect of public reporting on case selection for PCI is unknown. METHODS We compared demographics, indications, and outcomes of 11,374 patients included in a multicenter (eight hospitals) PCI database in Michigan where no public reporting is present, with 69,048 patients in a statewide (34 hospitals) PCI database in New York, where public reporting is present. The primary end point was in-hospital mortality. RESULTS Patients in Michigan more frequently underwent PCI for acute myocardial infarction (14.4% vs. 8.7%, p < 0.0001) and cardiogenic shock (2.56% vs. 0.38%, p < 0.0001) than those in New York. The Michigan cohort also had a higher prevalence of congestive heart failure and extracardiac vascular disease. The unadjusted in-hospital mortality rate was significantly lower in New York than in Michigan (0.83% vs. 1.54%, p < 0.0001; odds ratio [OR] 0.54, 95% confidence interval [CI] 0.45 to 0.63). However, after adjustment for comorbidities, there was no significant difference in mortality between the two groups (adjusted OR 1.05, 95% CI 0.84 to 1.31, p = 0.70, c-statistic 0.88). CONCLUSIONS There are significant differences in case mix between patients undergoing PCI in Michigan and New York that result in marked differences in unadjusted mortality rates. A propensity in New York toward not intervening on higher-risk patients because of fear of public reporting of high mortality rates is a possible explanation for these differences.

[1]  P. Romano,et al.  Do Well-Publicized Risk-Adjusted Outcomes Reports Affect Hospital Volume? , 2004, Medical care.

[2]  E. Hannan,et al.  The decline in coronary artery bypass graft surgery mortality in New York State. The role of surgeon volume. , 1995, JAMA.

[3]  A M Epstein,et al.  Use of public performance reports: a survey of patients undergoing cardiac surgery. , 1998, JAMA.

[4]  V. L. Clark,et al.  The Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) collaborative quality improvement initiative in percutaneous coronary interventions. , 2002, Journal of interventional cardiology.

[5]  P. Kligfield.  Primary angioplasty in myocardial infarction. , 1995, British heart journal.

[6]  K. Eagle,et al.  Development of a multicenter interventional cardiology database: the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) experience. , 2002, Journal of interventional cardiology.

[7]  T. Ryan,et al.  Multivariate prediction of in-hospital mortality after percutaneous coronary interventions in 1994-1996. Northern New England Cardiovascular Disease Study Group. , 1999, Journal of the American College of Cardiology.

[8]  David W Baker,et al.  The Effect of Publicly Reporting Hospital Performance on Market Share and Risk-Adjusted Mortality at High-Mortality Hospitals , 2003, Medical care.

[9]  E. Hannan,et al.  The relationship between managed care insurance and use of lower-mortality hospitals for CABG surgery. , 2000, JAMA.

[10]  W. Zareba,et al.  The influence of public reporting of outcome data on medical decision making by physicians. , 2005 .

[11]  Kirit Patel,et al.  Simple Bedside Additive Tool for Prediction of In-Hospital Mortality After Percutaneous Coronary Interventions , 2001, Circulation.

[12]  S. Jencks.  Clinical performance measurement--a hard sell. , 2000, JAMA.

[13]  J. Wennberg,et al.  A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. The Northern New England Cardiovascular Disease Study Group. , 1991, JAMA.

[14]  T. Brennan,et al.  A middle ground on public accountability. , 2004, The New England journal of medicine.

[15]  E. Hannan,et al.  Provider Profiling and Quality Improvement Efforts in Coronary Artery Bypass Graft Surgery: The Effect on Short-Term Mortality Among Medicare Beneficiaries , 2003, Medical care.

[16]  E J Topol,et al.  Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes. , 1996, Circulation.

[17]  N. Wintfeld,et al.  Report cards on cardiac surgeons. Assessing New York State's approach. , 1995, The New England journal of medicine.

[18]  Sharon-Lise T Normand,et al.  Physician clinical performance assessment: prospects and barriers. , 2003, JAMA.

[19]  J O'Keefe,et al.  A Comparison of Immediate Angioplasty with Thrombolytic Therapy for Acute Myocardial Infarction , 1993 .

[20]  M. Bell,et al.  Prediction of death after percutaneous coronary interventional procedures. , 2000, American heart journal.

[21]  W. Ghali,et al.  Statewide quality improvement initiatives and mortality after cardiac surgery. , 1997, JAMA.

[22]  H. Krumholz,et al.  Evaluation of a consumer-oriented internet health care report card: the risk of quality ratings based on mortality data. , 2002, JAMA.

[23]  Roderick J. A. Little,et al.  Statistical Analysis with Missing Data , 1988 .

[24]  Felix Hernandez,et al.  A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. The Northern New England Cardiovascular Disease Study Group. , 1991 .