Two new reports take on the shortcomings and unintended consequences of public reporting of percutaneous coronary intervention (PCI) outcomes more than two decades after it began.
The first report argues that public reporting of PCI outcomes has failed to achieve its primary objectives, but rather than railing against calls for national reporting of health outcomes it offers alternative approaches that may strengthen quality of care.
The second report provides striking details from a recent survey, in which 65% of interventional cardiologists said they have avoided indicated PCI at least twice because of concerns about public reporting. Further, less experienced interventionalists appear more likely to be risk-averse.
Senior author of the first paper, Deepak L. Bhatt, MD, MPH, Brigham and Women’s Hospital, Boston, Massachusetts, told theheart.org | Medscape Cardiology this has been a particular issue in Massachusetts, where all four authors are based and an early adopter of publicly reported PCI outcomes.
“If one is truly honest about it, there are cases of people that are really sick where there’s at least some doctors who think they might benefit from a trip to the cath lab, but there’s a reluctance to take them because it will make the numbers look bad,” he said. “That’s a really serious issue because it potentially means the sickest patients who may derive benefit are deprived of that opportunity.”
While the intentions of PCI public reporting are all good, Bhatt said it remains a “polarizing issue” and has failed to improve physician behavior and patient outcomes, accurately measure physician and institutional care quality, and engage patients to make informed decisions about their care.
To bolster the argument, several studies are cited showing limited access to PCI among the critically ill. In addition, a 2017 survey reports that while most patients who underwent PCI in New York believe physician-specific mortality data provide an accurate measure of physician quality, 95% had never heard of the state’s long-running public PCI reports and only 2.4% had actually viewed them. Instead, media outlets may be the “most rampant consumer of public reports,” note the authors, led by Rishi K. Wadhera, MD, Brigham and Women’s Hospital.
“Turning away from public reporting is not an option,” William B. Borden, MD, George Washington University, Washington, DC, said in an invited commentary published with the papers May 9, in JAMA Cardiology. “Despite the low public knowledge about PCI registries, the clear and strong societal trend is toward the public demanding more information and greater transparency.”
Toward More Meaningful Measures
Transparency is fueling national reporting efforts in healthcare, and “regardless of whether one thinks there is great value with that, that is the present and the future,” Bhatt agreed.
The authors propose several alternatives to current reporting efforts, including disease-based reporting, which is probably the “most immediately palatable,” Bhatt said. It would help reduce risk aversion and provide a more comprehensive assessment of care quality for specific subgroups, such as stable angina, ST-segment elevation myocardial infarction (STEMI), non-STEMI, and acute MI complicated by cardiogenic shock, where mortality is 50% or more.
“It might even lead to improvements in care because then everyone in the hospital is really aligned to do whatever is best, whether it’s PCI, surgery, medical therapy,” he said. “It’s not a perfect solution. There are still ways of being risk averse — early referral to palliative care that may or may not be appropriate depending on the circumstance…but at least it dilutes that potential because it is no longer procedure-specific but disease-specific.”
The Centers for Medicare & Medicaid Services already publicly reports hospital 30-day acute MI mortality. Expanding this to other acute MI disease subgroups and coupling performance on these measures with bundled payments “could create a powerful incentive to improve care quality and concomitantly address unintended consequences,” the authors suggest.
Other alternatives include reporting process-of-care measures, such as time to PCI for high-risk non-STEMI, and patient-centered outcomes, such as angina relief, quality of life, or exercise capacity. The latter could be more relevant and useful for patients than just reporting mortality, but there would be costs associated with tracking the additional outcomes, Bhatt said.
Finally, the authors float the idea of peer-driven, nonpublic-reporting programs, such as Michigan’s Collaborative Quality Initiatives, which has been shown to be associated with lower levels of physician risk aversion compared with New York’s public reporting program.
“Perhaps the best approach moving forward is a combination of disease-specific outcomes including patient-centric measures and procedure-specific process measures,” Borden writes in his commentary. “This dual method would capture the outcomes of greatest importance to patients while also providing actionable data to drive individual physician and hospital performance improvement.”
He goes on to describe the success of PCI public reporting efforts of the last couple decades as “underwhelming” and the authors’ proposals as providing an important foundation on which to improve.
“Wadhera et al provide a thoughtful blueprint for that path forward. Whatever the path that is chosen, it will require ongoing and careful research to assess both for success and for the inevitable unintended consequences that will arise,” Borden writes.
Rife With Risk Aversion
The second paper provides new multivariable and sensitivity analyses of an online survey reported last fall at the American Heart Association Scientific Sessions 2017.
Surveys were sent to 456 interventional cardiologists in New York and Massachusetts, both of which mandate public reporting of short-term mortality rates for PCI. Nearly all (94.6%) of the 149 respondents were male, their mean age was 49 years, and they had practiced interventional cardiology for a mean of 18.2 years. Most respondents practiced at medium to large hospitals with high-volume cardiac catheterization laboratories.
The survey is the first to examine public reporting in Massachusetts, and the Bay State garnered nearly twice the responses as New York (51.9% vs 25.1%), according to lead investigator, Daniel M. Blumenthal, MD, MBA, Beth Israel Deaconess Medical Center, Boston.
Overall, 4 in 5 respondents reported knowing some or a lot about public reporting systems’ risk adjustment methods but 73.8% had little or no trust in these methods. Three fourths of respondents (79.2%) believed public reporting of PCI outcomes did very little or nothing to help patients make more informed decisions about whether to undergo an elective PCI.
Notably, 59.1% of respondents reported being sometimes or often pressured by colleagues to avoid an indicated PCI in patients at high risk for death. Roughly half (51.7%) worried some or a lot that their superiors would not support them for performing an indicated PCI in a critically ill patient who later died of a PCI-related complication.
Interventionalists in Massachusetts and New York were equally likely to report avoiding high-risk PCIs.
In multivariate regression, more experience as an interventional cardiologist was the only significant predictor of lower odds of reporting pressure to avoid an indicated PCI (odds ratio per 1-year experience, 0.94; 95% CI, 0.90 – 0.98).
“We honestly didn’t know what we were going to find, and I think you could interpret this in a few ways,” Blumenthal told theheart.org | Medscape Cardiology. “You might interpret this to suggest that less experienced cardiologists feel less comfortable about practicing in a public-reporting environment and may feel less comfortable with their standing in their institution, or they may be more worried about how a decision they make could impact how their colleagues view them.”
A major limitation of the survey was the 32.7% response rate, which could limit generalizability outside the two states. However, a sensitivity analysis that inversely weighted responses by probability of survey completion “did not find significant differences in the findings and suggests that our responses are more likely to be generalizable to the broader population of cardiologists in Massachusetts and New York,” he said.
Further investigation is needed to understand the characteristics of physicians most susceptible to having their practice influenced in a negative way by working in public-reporting states, Blumenthal said.
“Given that we identified less experienced cardiologists as being in that group more likely to avoid indicated PCIs, it stands to reason we undertake efforts to understand why they may be more prone to risk-averse practice; and then target interventions towards that group of doctors that make them feel supported both at the institutional level and state and national levels to make the right decisions for patients at the point of care, regardless of how sick those patients are or how likely they are to have adverse outcomes,” he said. “I think that’s a really important point to emphasize.”
Bhatt reports serving on the advisory boards for and receiving research funding and royalties from multiple drug and device companies. Wadhera and Borden report having no relevant conflicts of interest. Blumenthal reports receiving research support from the John S LaDue Memorial Fellowship at Harvard Medical School and consulting fees and/or funding for unrelated work from Devoted Health, Novartis Pharmaceuticals, HLM Venture Partners, and Precision Health Economics.
JAMA Cardiol. Published online May 9, 2018. Wadhera abstract, Blumenthal abstract, Commentary
Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.
Tidak ada komentar:
Posting Komentar