We examined mandatory public reporting of patient outcomes for PCI and found that, compared to states without public reporting, states with reporting programs in place had substantially lower rates of PCI among their acute MI patients. The lower PCI rates were particularly pronounced for patients with STEMI, shock, or cardiac arrest. In Massachusetts, which adopted public reporting relatively recently, the initiation of public reporting was associated with a significant decrease in the odds of receiving PCI. We found no evidence that public reporting was associated with lower overall 30-day mortality rates for patients with acute MI.
There are at least two possible explanations for why public reporting was associated with lower rates of PCI for patients admitted for an acute MI. 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 due to concern over the risk of poor outcomes. While policymakers 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 comorbidities of their own patient population.1
Our data cannot definitively differentiate between these two potential mechanisms.
One way to ascertain whether the foregone procedures were appropriate or not is to examine mortality rates for AMI patients. In our analyses, we found that patients admitted for an acute MI had a somewhat higher mortality rate in public reporting states, although the differences were small, inconsistent, and usually not statistically significant. The weakness of this association suggests that the foregone procedures might have been a mix of appropriate and inappropriate PCIs. Another potential explanation for our mortality findings is that physicians in reporting states may have changed their coding practices in ways that made patients appear sicker than they actually were. These changes would likely bias our analyses away from finding an association between public reporting and worse outcomes. Therefore, although the lack of such an association is reassuring, we need new approaches to definitively understand whether outcomes were different in public reporting states.
Strategies to help clinicians differentiate between patients likely to benefit from PCI and patients for whom it would be futile are critically important. Promising work in this area is already underway.13,14
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. Massachusetts recently introduced a “compassionate use” category in their PCI reporting program that more accurately classifies extremely high-risk patients,15
and in 2008, New York began excluding patients in cardiogenic shock from its publicly reported outcomes.15
Whether these changes, instituted only recently, have been effective is not yet known. Follow-on data will be critical for determining if and how these policy changes influence patient selection for PCI.
Our findings are consistent with prior reports from single-state public reporting experiences. A study examining public reporting in the 1990s found that patients in New York were significantly less likely to undergo PCI after an acute MI than comparable patients in Michigan, a state without reporting.16
A more recent analysis of a small registry of patients with cardiogenic shock found that New York patients in shock were less likely than non–New York patients in shock to undergo PCI; in this study, the lower access to PCI was associated with higher mortality, although in a significantly younger population than our study.3
Studies examining public reporting and access to CABG surgery have yielded more mixed results, with some studies suggesting decreased access6,8
and others not demonstrating this relationship.7
Our study has several limitations. First, while we focused our analyses on patients admitted for an acute MI, public reporting targeted all patients undergoing PCI, and we could not determine whether public reporting was associated with a mortality benefit for non-MI patients. Of course, patients undergoing PCI for indications other than acute MI have very low mortality rates (0.65% in data from the National Cardiovascular Data Registry).14
Second, there was substantial heterogeneity within the public reporting states. For example, two of the three states only reported outcomes for hospitals while the third also reported outcomes for individual clinicians. Each state’s system for adjudication and monitoring of data is different. Finally, one of the three states (Massachusetts) expanded access to health insurance during the study period, which could have increased demand for PCI. Therefore, whether our results would be generalizable to all other states contemplating public reporting is unclear.
Because we used administrative data, we were unable to determine whether PCI was the most appropriate treatment in any specific clinical situation. However, indications for PCI should not be substantively different in public reporting states than in control states, and should not have changed over time in Massachusetts. Further, our use of administrative data limited our ability to fully account for potential up-coding by hospitals in public reporting states. We attempted to address this limitation by examining unadjusted outcomes. Additionally, any upcoding in the public reporting states should bias us towards finding better outcomes after the advent of public reporting. Thus, our findings may actually underestimate the relationship between public reporting and PCI utilization or outcomes. Finally, our analysis was limited to Medicare patients over the age of 65. Whether our findings would extend to a younger patient population is unclear.