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Fewer Heart Attack Victims Treated with Angioplasty and Stents in States with Mandatory Public Reporting
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Ambulance arriving at hospital with heart attack victim
October 16, 2012 -- A study, appearing in the current Journal of the American Medical Association (JAMA), looked at almost 100,000 heart attack patients in ten Northeastern states and found that, in those states where public reporting of outcomes was mandatory, 12% fewer angioplasty and stent procedures were performed.

This is an significant observation because angioplasty (a.k.a. PCI, or Percutaneous Coronary Intervention) is considered the "gold standard" for the treatment of heart attacks. Today a patient suffering an acute myocardial infarction can arrive at an acute care hospital and have the blocked artery that is causing the heart attack opened up with a balloon and/or stent within 90 minutes, stopping the heart attack in its tracks, and preserving the heart muscle. A heart attack no longer condemns the victim to a lifetime of reduced activity, loss of work, and early death.

Why Is the Rate of PCI Lower in Reporting States?
The marked reduction in treating heart attack patients with PCI in reporting states is of concern to practitioners for several reasons. Are hospitals and doctors in reporting states avoiding high risk patients whose worse outcomes will lower their publicly-viewed rating? Or has public reporting helped doctors in these states become more able to discern which patients will benefit from PCIs and which patients are too sick or who have multiple clinical issues that render an intervention basically futile? While the study in JAMA was not able to answer these questions directly, there are data that might support both scenarios. The authors write:

"It is possible that many of the foregone procedures were futile or unnecessary, and public reporting focused clinicians on ensuring that only the most appropriate procedures were performed. Alternatively, public reporting may have led clinicians to avoid PCI in eligible patients because of concern over the risk of poor outcomes. Although policy makers have made efforts to ensure that risk adjustment models account for patient complexity, prior qualitative work suggests that clinicians remain concerned about receiving adequate 'credit' for the comorbid conditions of their own patient population. Our data cannot definitively differentiate between these 2 potential mechanisms."

Karen E. Joynt, MD, MPH
Karen E. Joynt, MD, MPH
Study Methods and Results
The study was conducted by Karen E. Joynt, MD, MPH, of the Harvard School of Public Health, Boston, and her team, using Medicare data from heart attack patients admitted to acute care hospitals in ten Northeastern states between 2002 and 2010. There were 49,660 patients from the public reporting states of New York, Massachusetts, and Pennsylvania; and 48,142 from the non-reporting states of Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland, and Delaware. The results: 37.7% of heart attack patients in the reporting states received angioplasties, compared to 42.7% in those states without reporting. Patients in New York, Pennsylvania and Massachusetts were 12% less likely to have their artery opened up with a stent.

The Observer Affects The Observed
One finding was unequivocal: instituting mandatory reporting reduced the number of angioplasty procedures performed. Over the past two decades, three states passed requirements for public reporting of PCI procedures, starting in 1991 for New York, followed by Pennsylvania in 2001 and Massachusetts in 2005. The hope was that patients and professionals could look at these data to make choices and improvements. In earlier studies of PCI-only patients comparing New York and Michigan, a non-reporting state, a lower rate of PCIs was seen across-the-board in New York, both in acute and stable patients. But this week's study in JAMA is the first time a large group of emergency patients were compared, and the study group included those who did and did not receive angioplasty, and those in reporting and non-reporting states.

In case there was any question whether or not there was a direct relationship between public reporting and frequency of PCI, the authors also tabulated results from Massachusetts only: a unique situation because mandatory reporting started in 2005, in the middle of the study data range. Sure enough, during the years from 2002-2005, when Massachusetts did not require reporting, its PCI rate was similar to other non-reporting states. But when reporting started, the PCI rate went down surprisingly quickly to the level of New York and Pennsylvania.

How Did Lower Rates of PCI Affect Patient Outcomes?
One main finding of the study was that 30-day mortality did not differ between patients in public reporting or non-reporting states. The unadjusted rates were 12.8% vs. 12.1% respectively. Generally speaking it seemed as if the lower rate of PCI in the reporting states did not increase mortality; put another way, the increased use of PCI in the non-reporting states did not improve outcomes.

However, there are caveats regarding mortality figures: in the STEMI subgroup, a group for whom PCI is the "gold standard" of treatment, 30-day mortality was higher (13.5% vs. 11.0%) in the reporting states where PCI was used less often. Also, the negative effects of heart muscle damage may not show up within the immediate 30-day period, but may contribute to death and disability over the longer term. Angioplasty.Org asked Dr. Joynt about this possibility and she replied:

"Your idea to look at longer-term outcomes is a good one – and gets to a larger issue – when we do public reporting, we rely on data that only provides us with a brief snapshot of what's happening at a hospital. I don't know whether longer-term outcomes could be worse in the patients who don't get PCI, as you suggest – but we didn't test that possibility in this project. Something that would be very helpful for patients and clinicians is if we could develop better tools to identify which patients would really benefit from PCI and which might not."

One other important factor, of course, is that this study is based entirely on claims data from Medicare patients, that is, patients 65 and older. Angioplasty.Org asked Dr. Mauro Moscucci, author of an accompanying editorial in JAMA, if age range was a limitation and he replied that, "The findings might be very different with younger patients."

In his editorial, "Public Reporting of PCI Outcomes and Quality of Care One Step Forward and New Questions Raised," Dr. Moscucci of the University of Miami Miller School of Medicine, also discussed the issue of the apparent discrepancy of lower PCI usage with no overall affect on mortality, raising the issue of an additional reason:

"A third possible explanation is that risk adjustment requires optimal coding of comorbid conditions and is subject to gaming through up-coding, thus leading to observed outcomes that are better than predicted. Better coding in public reporting states might have mitigated the adverse effect of denial of care after risk adjustment. However, a perceived limitation of this study is its failure to tease out the reason that, despite lower referral for PCI in public reporting states, the overall 30- day mortality remained the same. Separate analysis limited to patients receiving and not receiving PCI could have helped in answering this question."

Public Reporting is a Growing Phenomenon
The JAMA study has generated a wide spectrum of opinion in a number of online journals. Some "stent-overuse" advocates claim that the study shows that there is no downside in lowering the rate of PCI; other physicians expressed concern about an unintentional side-effect of public reporting: that the patients who need angioplasty most (STEMI victims) may be denied or delayed in receiving the best care. As for the "inappropriate use" of PCI, as Dr. Moscucci told Angioplasty.Org, "In acute myocardial infarction, there is no 'inappropriate use'."

One fact that all agree on: mandatory public reporting is a movement that is growing and that refining the parameters and accuracy of these reports is crucial. As Dr. Joynt et al conclude:

"Strategies to help clinicians differentiate between patients likely to benefit from PCI and those for whom it would be futile are critically important. Promising work in this area is already underway. Providing real-time models of both risk and benefit may help physicians, patients, and families make more informed decisions about when to pursue PCI. Similarly, strategies to provide adequate credit for taking care of the sickest patients would also be useful."

Reported by Burt Cohen, October 16, 2012