Public reporting of PCI outcomes affects cardiologists’ decision-making

JAMA Cardiology tackled the issue of publicly reporting percutaneous coronary intervention (PCI) outcomes in its latest issue, publishing three pieces on the topic.

The most comprehensive paper of the three—a special communication by corresponding author Deepak L. Bhatt, MD, MPH, and colleagues—contended interventional cardiologists feel pressured to avoid PCIs in high-risk patients for fear of public shaming. What’s more, the mortality rates assessed might not be the best way to measure quality of care, they wrote, and patients are unlikely to view this information anyway.

Taken together, this suggests that the added transparency is actually of little benefit to patients, but the cautious behavior by physicians wary of public reporting may lead to patient harm.

“In general, the likelihood of receiving PCI for AMI (acute myocardial infarction) has been shown to be lower in states with reporting programs compared with states without,” Bhatt and colleagues wrote. “These patterns would be desirable if they definitively reflected a reduction in inappropriate or futile cases, but lower rates of PCI in states with reporting programs have been most pronounced among patients—such as those with AMI complicated by cardiogenic shock—who may stand to gain the most from intervention.”

Indeed, in a separately published brief report, lead author Daniel M. Blumenthal, MD, MBA, and colleagues found a majority of physicians change their decision-making as a result of public reporting. Analyzing survey responses from 149 physicians from Massachusetts and New York—two of the five states with mandatory reporting—the researchers concluded 65 percent of interventional cardiologists have avoided PCI on at least two occasions out of concern for how it would impact their publicly reported outcomes. In addition, 59 percent reported being sometimes or often pressured by colleagues to avoid PCI due to a patient’s death risk.

“This suggests that PCI avoidance is not concentrated among a few risk-averse interventionalists,” wrote Blumenthal and colleagues, adding that more experienced cardiologists were less likely to avoid PCIs.

“While we did not quantify rates of PCI avoidance among clinicians who acknowledged avoiding PCIs, any avoidance of an indicated procedure is concerning. Modifying public reporting systems to include all patients experiencing acute myocardial infarction, as opposed to patients undergoing PCIs alone, is a promising approach for further reducing risk-averse use of PCIs.”

Bhatt et al. said publicly reporting time to PCI or time to aspirin administration may be a better measurement of care, and improving those processes would likely lead to lower PCI mortality. They added that for non-urgent PCIs, patient-reported quality of life outcomes may be the most useful for other patients considering an elective procedure. Publicly reporting any of these results could be more informative to the patient and better contextualize the level of care provided than raw mortality rates, the authors noted.

Bhatt et al. suggested sharing outcomes between institutions, away from the public limelight, may also have the desired benefits of reporting initiatives without the drawbacks affecting patient care.

“A formal system of sharing outcome information among physicians and institutions within a state would promote accountability and enable peer-reviewed analyses and coaching to improve care quality,” the authors wrote. “In addition, given that fear of public shame is likely what drives physicians to alter their clinical decision making … completely removing the ‘public’ element of reporting might help address these behaviors.”

But William B. Borden, MD, with George Washington University, said an invited commentary public reporting in some fashion is here to stay. It’s simply what consumers demand today.

“The clear and strong societal trend is toward the public demanding more information and greater transparency,” he wrote. “Empowering individuals with knowledge is a good thing. That knowledge must be as accurate as possible and presented with proper context so that patients can make appropriate informed decisions, and physicians and hospitals can adapt care delivery to improve health outcomes and equity, rather than the converse.”