Public Reporting for PCI, Cardiogenic Shock: Clarity or Confusion?

Patrice Wendling

August 11, 2016

NEW YORK — Excluding cardiogenic shock from publicly reported PCI mortality outcomes in New York appears to have cut down on the cherry picking of lower- risk patients, the very concern that prompted the exclusion.

New Yorkers with acute MI complicated by cardiogenic shock (AMI-CS) were more likely to be treated with PCI after the 2006 shock exclusion, but rates of PCI and revascularization in the Empire state still persistently lag behind those in nonreporting states, a pair of studies finds[1,2].

"Although perhaps helpful," the policy change "still did not do enough to encourage physicians to take care for the sickest patients who had the most to lose," Dr Ajay Kirtane (Columbia University Medical Center, NY) and colleagues write in an editorial[3] that accompanied the two reports published online July 27, 2016 in JAMA Cardiology.

They point out that elective PCI is a vastly different procedure from high-risk scenarios like AMI-CS, where mortality may reach 50% and physicians may have little control over outcomes. Still, "in some ways, we have conflated reporting on the procedure with reporting on the condition. It is akin to describing outcomes for a colon resection regardless of whether the indication was for a gunshot wound to the abdomen, diverticulosis, or a large high-risk polyp."

Dr Mehdi Shishehbor (Cleveland Clinic, OH), who was not involved in the study, sounded a similar note in his comments to heartwire from Medscape. "The biggest issue is that we have a flawed system that focuses more on the procedures rather than the diagnosis, meaning we don't have public reporting for patients with cardiogenic shock getting admitted to hospitals to see what their outcomes are but we do have public reporting if the patient has a procedure," he said.

New York Report

The first report[1], led by Dr Sripal Bangalore (New York University School of Medicine, NY), used the National Inpatient Sample to compare outcomes for 2126 propensity score-matched patients with AMI-CS in New York and Michigan over three time periods: 2002 to 2005, when cardiogenic shock was included in publicly reported outcomes in New York; 2006 to 2007, when shock was excluded on a trial basis; and from 2008 onward, when shock was permanently excluded.

Adjusted analyses revealed a 19% increase in the proportion of New Yorkers who underwent PCI after the exclusion of cardiogenic shock from public reporting (time 1 vs time 3) (adjusted relative risk [aRR] 1.19, 95% CI 0.96–1.45; P=0.11).

Over the same periods in Michigan, however, PCI for cardiogenic shock increased by 40% (aRR 1.40, 95% CI 1.18–1.60; P<0.001).

While rates of CABG held steady, New Yorkers were more likely after the shock exclusion to undergo invasive management (any cardiac catheterization, PCI, or CABG) or revascularization, but again there was a greater increase in these procedures in Michigan.

Additional analyses of patients in the nonreporting states of New Jersey and California also yielded largely similar results.

Bangalore and colleagues note that while comorbidities and patient preference may play a role, "one of the more likely reasons for the observed low rates of PCI in New York could still be continued reluctance to perform interventions on high-risk cases."

Another factor could be New York's strict definition of cardiogenic shock that qualifies for exemption from public reporting.

Kirtane and colleagues write, "Although stringent criteria for shock are needed to ensure that there is no upcoding or 'gaming' of the system, in our experience, based on 10 years of observation within New York, the current exclusion (which at least ought to be adopted in states that currently publicly report PCI mortality) still may not go far enough, and these comparative utilization rates support this assertion."

Washington Report

The second report[2], led by Dr James McCabe (University of Washington, Seattle), used several statewide hospitalization databases to examine data for 45,977 patients diagnosed with AMI-CS between 2002 and 2012.

After adjustment for patient factors, New York operators were 28% more likely to perform PCI on patients with AMI-CS after the 2006 policy change (aRR 1.28, 95% CI 1.19–1.37; P<0.001). This compares with a 9% increase in PCI after 2006 among operators in California, Massachusetts, Michigan, and New Jersey (aRR 1.09; 95% CI 1.05–1.13; P<0.001).

When all forms of revascularization were included in the analysis, there was a 15% increased rate of revascularization for shock in New York after 2006 (aRR 1.15, 95% CI 1.09–1.22; P<0.001) compared with a nonsignificant change in the other states (aRR 1.03, 95% CI 1.00–1.06; P=0.72).

But Are They Dying?

The adjusted risk of in-hospital death for all New Yorkers with AMI-CS dropped 24% after the shock exclusion (aRR 0.76, 95% CI 0.72–0.81; P<0.001) but declined only 9% during the same period in the four comparator states (aRR 0.91, 95% CI 0.87–0.94; P<0.001), McCabe reports.

Still, because New York started with far lower rates of revascularization and in-hospital death for AMI-CS, it continued to have lower overall rates of revascularization at the end of the study period despite the bigger bump in the use of revascularization, he noted.

Bangalore et al report that in-hospital mortality did not change in AMI-CS patients undergoing PCI, revascularization, invasive management, or CABG in New York or Michigan after the shock exclusion.

Shishehbor said that to some degree the mortality finding is reassuring but difficult to interpret without a clear understanding of whether patients who come in with cardiogenic shock should be revascularized or not to begin with.

Further, the analyses did not look at long-term mortality and other outcomes related to AMI-CS like heart failure, length of hospital stay, NYHA classification afterward, and placement in a long-term care facility that are important to patients.

Editorialists Kirtane and colleagues conclude, "It may simply be time to recognize that mortality following PCI is the wrong metric with which to arbitrate its quality across heterogeneous patient scenarios, despite attempts to separate these scenarios into discrete entities, such as shock and nonshock."

Commenting to heartwire , Dr Mauro Moscucci (LifeBridge Health Cardiovascular Institute, Sinai Hospital of Baltimore, MD), who was not involved in the studies, said the 2006 shock exclusion appears to have increased PCI rates in New York but agreed with the editorialists that other approaches are needed.

They note that Michigan opted to bypass public reporting and instead established the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2), which over time has shown to have a positive impact on PCI processes of care.

Maryland has taken a different tack in the wake of the high-profile lawsuits over unnecessary stent placements and now requires physicians send out 10% of their cases for peer review. "It's really policing us physicians, which is unfortunate, but I can tell you everyone is being extremely careful in the lesions they do, how they do it, and the documentation they provide," Moscucci said.

He added, "We haven't solved this issue. There have been numerous papers trying to address this, and there is still much more work we need to do regarding public reporting and how to mitigate some of the adverse consequences."

Bangalore reported no relevant financial relationships. Disclosures for the coauthors are listed in the article. The McCabe project was funded by Massachusetts General Hospital's Hassenfeld Scholar Award and the Richard and Susan Smith Center for Outcomes Research. The authors report no relevant financial relationships. Kirtane reports institutional research grants from Medtronic Cardiovascular, Boston Scientific, Abiomed, Abbott Vascular, St Jude Medical, Eli Lilly, and GlaxoSmithKline. Coeditorialists Nallamothu and Moses as well as Shishehbor and Moscucci report no relevant financial relationships.

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