Public Reporting and Case Selection for Percutaneous Coronary Interventions

Influence of Major Adverse Events on Procedural Selection for Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment Reporting and Tracking Program

Background

Public reporting of percutaneous coronary intervention (PCI) outcomes has been associated with risk-averse attitudes, and pressure to avoid negative outcomes may hinder the care of high-risk patients referred for PCI in public reporting environments. It is unknown whether the occurrence of PCI-related major adverse events (MAEs) influences future case selection in nonpublic reporting environments. Here, we describe trends in PCI case selection among patients undergoing coronary angiography following MAEs in Veterans Affairs (VA) cardiac catheterization laboratories participating in a mandatory internal quality improvement program without public reporting of outcomes.

Methods

Patients who underwent coronary angiography between October 1, 2010, and September 30, 2018, were identified and stratified by VA 30-day PCI mortality risk. The association between MAEs and changes in the proportion of patients proceeding from coronary angiography to PCI within 14 days was assessed.

Results

A total of 251,526 patients and 913 MAEs were included in the analysis. For each prespecified time period of 1, 2, and 4 weeks following an MAE, there were no significant changes in the proportion of patients undergoing coronary angiography who proceeded to PCI within 14 days for the overall cohort and for each tercile of VA 30-day PCI mortality risk.

Conclusions

There were no deviations from routine PCI referral practices following MAEs in this analysis of VA cardiac catheterization laboratories. Nonpublic reporting environments and quality improvement programs may be influential in mitigating PCI risk-aversion behaviors.

Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives: A Systematic Review

An essential element in the pursuit of value-based health care is provider payment reform. This article aims to identify and analyze payment initiatives comprising a specific manifestation of value-based payment reform that can be expected to contribute to value in a broad sense: (a) global base payments combined with (b) explicit quality incentives. We conducted a systematic review of the literature, consulting four scientific bibliographic databases, reference lists, the Internet, and experts. We included and compared 18 initiatives described in 111 articles/documents on key design features and impact on value. The initiatives are heterogeneous regarding the operationalization of the two payment components and associated design features. Main commonalities between initiatives are a strong emphasis on primary care, the use of "virtual" spending targets, and the application of risk adjustment and other risk-mitigating measures. Evaluated initiatives generally show promising results in terms of lower spending growth with equal or improved quality.

The Role of National Registries in Improving Quality of Care and Outcomes for Cardiovascular Disease

Cardiovascular registries play an integral role in providing real-world data on a number of cardiovascular conditions and allowing measurement of quality metrics across a large cohort of patients. Over the past 35 years, the number of cardiovascular registries has skyrocketed, and their use will only continue to grow as data on novel procedures and devices will need to be collected and analyzed. The American College of Cardiology and Society of Thoracic Surgeons Transcatheter Valve Therapy Registry is just one example of a modern registry that plays a crucial role in collecting data on patients undergoing transcatheter valvular procedures. Through public reporting registries, data can be shared on a hospital and provider level for many quality performance measures. There remains much work to be done on allowing automated data extraction from the electronic medical record directly into registries. No matter how sophisticated and complete a registry is, it can never overcome the problem of treatment selection bias that is inherent in observational data. This review discusses the growth, benefits, and limitations of national registries and their role in developing evidence for best clinical practice, measuring outcomes, providing feedback to clinicians, and improving quality of care.

Public Reporting of Cardiac Outcomes for Patients With Acute Myocardial Infarction: A Systematic Review of the Evidence

BACKGROUND

Percutaneous coronary intervention (PCI) is recognized by both the American Heart Association and the American College of Cardiology as an optimal therapy to treat patients experiencing acute myocardial infarction (AMI) with ST-segment elevation myocardial infarction. A health policy aimed at improving outcomes for the patient with AMI is public reporting of whether a patient received a PCI.

OBJECTIVE

A systematic review was conducted to evaluate the effect of public reporting for patients with AMI, specifically for those patients who receive PCI.

METHODS

EMBASE, MEDLINE, Academic Search Premier, Google Scholar, and PubMed were searched from inception through August 2017. Articles were selected for inclusion if researchers evaluated public reporting and included an outcome for whether a patient received a PCI during hospitalization for an AMI. Methodological quality of the included studies was evaluated, and findings were synthesized.

RESULTS

Eight studies of high methodological quality were included in the review. Most studies found that, in areas of public reporting, patients were less likely to undergo a PCI and high-risk patients did not undergo a PCI. Researchers also found that patients with AMI had lower in-hospital mortality after the implementation of public reporting, but only if these patients received a PCI.

CONCLUSIONS

Although public reporting may have had intentions of improving care, there is strong evidence that this policy did not result in more timely PCIs or improved mortality of patients with AMI. In fact, public reporting resulted in unintended consequences of not providing care for the most vulnerable patients in fear of an adverse outcome.

Association between Public Reporting of Outcomes and the Use of Mechanical Circulatory Support in Patients with Cardiogenic Shock

Risk-averse behavior has been reported among physicians and facilities treating cardiogenic shock in states with public reporting. Our objective was to evaluate if public reporting leads to a lower use of mechanical circulatory support in cardiogenic shock. We conducted a retrospective study with the use of the National Inpatient Sample from 2005 to 2011. Hospitalizations of patients ≥18 years old with a diagnosis of cardiogenic shock were included. A regional comparison was performed to identify differences between reporting and nonreporting states. The main outcome of interest was the use of mechanical circulatory support. A total of 13043 hospitalizations for cardiogenic shock were identified of which 9664 occurred in reporting and 3379 in nonreporting states (age 69.9 ± 0.4 years, 56.8% men). Use of mechanical circulatory support was 32.8% in this high-risk population. Odds of receiving mechanical circulatory support were lower (OR 0.50; 95% CI 0.43-0.57; p < 0.01) and in-hospital mortality higher (OR 1.19; 95% CI 1.06-1.34; p < 0.01) in reporting states. Use of mechanical circulatory support was also lower in the subgroup of patients with acute myocardial infarction and cardiogenic shock in reporting states (OR 0.61; 95% CI 0.51-0.72; p < 0.01). In conclusion, patients with cardiogenic shock in reporting states are less likely to receive mechanical circulatory support than patients in nonreporting states.

Association Between Current and Future Annual Hospital Percutaneous Coronary Intervention Mortality Rates

Importance

Multiple states publicly report a hospital's risk-adjusted mortality rate for percutaneous coronary intervention (PCI) as a quality measure. However, whether reported annual PCI mortality is associated with a hospital's future performance is unclear.

Objective

To evaluate the association between reported risk-adjusted hospital PCI-related mortality and a hospital's future PCI-related mortality.

Design, Setting, and Participants

This study used data from the New York Percutaneous Intervention Reporting System from January 1, 1998, to December 31, 2016, to assess hospitals that perform PCI.

Exposures

Public-reported, risk-adjusted, 30-day mortality after PCI.

Main Outcomes and Measures

The primary analysis evaluated the association between a hospital's reported risk-adjusted PCI-related mortality and future PCI-related mortality. The correlation between a hospital's observed to expected (O/E) PCI-related mortality rates each year and future O/E mortality ratios was assessed. Multivariable linear regression was used to examine the association between index year O/E mortality and O/E mortality in subsequent years while adjusting for PCI volume and patient severity.

Results

This study included 67 New York hospitals and 960 hospital-years. Hospitals with low PCI-related mortality (O/E mortality ratio, ≤1) and high mortality (O/E mortality ratio, >1) had inverse associations between their O/E mortality ratio in the index year and the subsequent change in the ratio (hospitals with low mortality, r = -0.45; hospitals with high mortality, r = -0.60). Little of the variation in risk-adjusted mortality was explained by prior performance. An increase in the O/E mortality ratio from 1.0 to 2.0 in the index year was associated with a higher O/E mortality ratio of only 0.15 (95% CI, 0.02-0.27) in the following year.

Conclusions and Relevance

At hospitals with high or low PCI-related mortality rates, the rates largely regressed to the mean the following year. A hospital's risk-adjusted mortality rate was poorly associated with its future mortality. The annual hospital PCI-related mortality may not be a reliable factor associated with hospital quality to consider in a practice change or when helping patients select high-quality hospitals.

Public Reporting of Percutaneous Coronary Intervention Outcomes: Moving Beyond the Status Quo

Importance

More than 20 years have passed since public reporting of percutaneous coronary intervention (PCI) outcomes first began in New York State, but reporting remains a polarizing issue.

Observations

Advocates of public reporting point to the strong incentive that public disclosure of outcomes data provides for institutions and clinicians to improve clinical care and to the importance of enabling patients to make informed choices about their care. Critics highlight the methodological challenges that impede fair and accurate assessments of care quality as well as reporting's unintended consequences. Public reporting of PCI outcomes has only been implemented in 5 states, but reporting efforts for multiple conditions and procedures are now proliferating nationally, propelled by the notion that transparency improves the quality of health care and fosters trust in health care institutions. Careful evaluation of the evidence to date for PCI in particular, however, suggests that enthusiasm for such efforts should be tempered.

Conclusions and Relevance

Public reporting has not achieved its primary objectives. Policy makers should consider variations of reporting that might strengthen care quality, empower patients, and mitigate undesirable repercussions.

The Impact of Public Performance Reporting on Market Share, Mortality, and Patient Mix Outcomes Associated With Coronary Artery Bypass Grafts and Percutaneous Coronary Interventions (2000-2016): A Systematic Review and Meta-Analysis

Supplemental Digital Content is available in the text.

Objective:

Public performance reporting (PPR) of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) outcomes aim to improve the quality of care in hospitals, surgeons and to inform consumer choice. Past CABG and PCI studies have showed mixed effects of PPR on quality and selection. The aim of this study was to undertake a systematic review and meta-analysis of the impact of PPR on market share, mortality, and patient mix outcomes associated with CABG and PCI.

Methods:

Six online databases and 8 previous reviews were searched for the period 2000–2016. Data extraction, quality assessment, systematic critical synthesis, and meta-analysis (where possible) were carried out on included studies.

Results:

In total, 22 relevant articles covering mortality (n=19), patient mix (n=14), and market share (n=6) outcomes were identified. Meta-analyses showed that PPR led to a near but not significant reduction in short-term mortality for both CABG and PCI. PPR on CABG showed a positive effect on market share for hospitals (3 of 6 studies) and low-performing surgeons (2 of 2 studies). Five of 6 PCI studies found that high-risk patients were less likely to be treated in States with PPR.

Conclusions:

There is some evidence that PPR reduces mortality rates in CABG/PCI-treated patients. The significance of there being no strong evidence, in the period 2000–2016, should be considered. There is need for both further development of PPR practice and further research into the intended and unintended consequences of PPR.

Association of acute myocardial infarction cardiac arrest patient volume and in-hospital mortality in the United States: Insights from the National Cardiovascular Data Registry Acute Coronary Treatment And Intervention Outcomes Network Registry

BACKGROUND

Little is known about how differences in out of hospital cardiac arrest patient volume affect in-hospital myocardial infarction (MI) mortality.

HYPOTHESIS

Hospitals accepting cardiac arrest transfers will have increased hospital MI mortality.

METHODS

MI patients (ST elevation MI [STEMI] and non-ST elevation MI [NSTEMI]) in the Acute Coronary Treatment Intervention Outcomes Network Registry were included. Hospital variation of cardiac arrest and temporal trend of the proportion of cardiac arrest MI patients were explored. Hospitals were divided into tertiles based on the proportion of cardiac arrest MI patients, and association between in-hospital mortality and hospital tertiles of cardiac arrest was compared using logistic regression adjusting for case mix.

RESULTS

A total of 252 882 patients from 224 hospitals were included, of whom 9682 (3.8%) had cardiac arrest (1.6% of NSTEMI and 7.5% of STEMI patients). The proportion of MI patients who had cardiac arrest admitted to each hospital was relatively low (median 3.7% [25th, 75th percentiles: 3.0%, 4.5%]).with a range of 4.2% to 12.4% in the high-volume tertiles. Unadjusted in-hospital mortality increased with tertile: low 3.8%, intermediate 4.6%, and high 4.7% (P < 0.001); this was no longer significantly different after adjustment (intermediate vs high tertile odds ratio (OR) = 1.02; 95% confidence interval [0.90-1.16], low vs high tertile OR = 0.93 [0.83, 1.05]).

CONCLUSIONS

The proportion of MI patients who have cardiac arrest is low. In-hospital mortality among all MI patients did not differ significantly between hospitals that had increased proportions of cardiac arrest MI patients. For most hospitals, overall MI mortality is unlikely to be adversely affected by treating cardiac arrest patients with MI.

Current quality reporting methods are not adequate for salvage cardiac operations

OBJECTIVES

Outcomes in cardiac surgery are benchmarked against national Society of Thoracic Surgeons (STS) data and include patients undergoing elective, urgent, emergent, and salvage operations. This practice relies on accurate risk adjustment to avoid risk-averse behavior. We hypothesize that the STS risk calculator does not adequately characterize the risk of salvage operations because of their heterogeneity and infrequent occurrence.

METHODS

Data on all cardiac surgery patients with an STS predicted risk score (2002-2017) were extracted from a regional database of 19 cardiac surgery centers. Patients were stratified according to operative status for univariate analysis. Observed-to-expected (O:E) ratios for mortality and composite morbidity/mortality were calculated and compared among elective, urgent, emergent, and salvage patients.

RESULTS

A total of 76,498 patients met inclusion criteria. The O:E mortality ratios for elective, urgent, and emergent cases were 0.96, 0.98, and 0.93, respectively (all P values > .05). However, mortality rate was significantly higher than expected for salvage patients (O:E ratio, 1.41; P = .04). Composite morbidity/mortality rate was lower than expected in elective (O:E ratio, 0.81; P = .0001) and urgent (O:E ratio, 0.93; P = .0001) cases but higher for emergent (O:E ratio, 1.13; P = .0006) and salvage (O:E ratio, 1.24; P = .01). O:E ratios for salvage mortality were highly variable among each of the 19 centers.

CONCLUSIONS

The current STS risk models do not adequately predict outcomes for salvage cardiac surgery patients. On the basis of these results, we recommend more detailed reporting of salvage outcomes to avoid risk aversion in these potentially life-saving operations.

Survival after non-resection of colorectal cancer: the argument for including non-operatives in consultant outcome reporting in the UK

INTRODUCTION

Although the mainstay of colorectal cancer treatment remains operative, a significant proportion of patients end up without surgery. This is because they are either deemed to have no oncological benefit from the resection (too much disease) or to be unfit for major surgery (too frail). The aim of this study was to assess the proportion and survival of these two groups among the totality of practice in a tertiary unit and to discuss the implications on the conceptual understanding of outcome measures.

METHODS

Data was collected over two study periods with the total duration of four years. Patient demographics, comorbidities, cancer staging and management pathways were all recorded. The primary endpoint was all-cause mortality.

RESULTS

The total of 909 patients were examined. In the 29% who did not undergo resectional surgery, 6.5% had too little disease, 13.8% had too much disease, while 8.7% were deemed too frail. The highest two-year mortality was observed in the too much (83.2%) and too frail (75.9%) groups, whereas in patients with too little cancer the rate was 5.1%, and in those undergoing a resection it was 19.2% (P < 0.001).

CONCLUSIONS

The study has expectedly shown poor survival in the too much and too frail groups. We believe that understanding the prognosis in these subgroups is vital, as it informs complex decisions on whether to operate. Moreover, an overall reporting taking into account the proportion of these groups in an multidisciplinary team practice (the non-surgical index) is proposed to render individual surgeon's mortality results meaningful as a comparative measure.

Impact of public release of performance data on the behaviour of healthcare consumers and providers

BACKGROUND

It is becoming increasingly common to publish information about the quality and performance of healthcare organisations and individual professionals. However, we do not know how this information is used, or the extent to which such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers, and purchasers.

OBJECTIVES

To estimate the effects of public release of performance data, from any source, on changing the healthcare utilisation behaviour of healthcare consumers, providers (professionals and organisations), and purchasers of care. In addition, we sought to estimate the effects on healthcare provider performance, patient outcomes, and staff morale.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trials registers on 26 June 2017. We checked reference lists of all included studies to identify additional studies.

SELECTION CRITERIA

We searched for randomised or non-randomised trials, interrupted time series, and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or professionals. Each study had to report at least one main outcome related to selecting or changing care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers, and healthcare purchasers), performance data, main outcomes (choice of healthcare provider, and improvement by means of changes in care), and other outcomes (awareness, attitude, knowledge of performance data, and costs). Given the substantial degree of clinical and methodological heterogeneity between the studies, we presented the findings for each policy in a structured format, but did not undertake a meta-analysis.

MAIN RESULTS

We included 12 studies that analysed data from more than 7570 providers (e.g. professionals and organisations), and a further 3,333,386 clinical encounters (e.g. patient referrals, prescriptions). We included four cluster-randomised trials, one cluster-non-randomised trial, six interrupted time series studies, and one controlled before-after study. Eight studies were undertaken in the USA, and one each in Canada, Korea, China, and The Netherlands. Four studies examined the effect of public release of performance data on consumer healthcare choices, and four on improving quality.There was low-certainty evidence that public release of performance data may make little or no difference to long-term healthcare utilisation by healthcare consumers (3 studies; 18,294 insurance plan beneficiaries), or providers (4 studies; 3,000,000 births, and 67 healthcare providers), or to provider performance (1 study; 82 providers). However, there was also low-certainty evidence to suggest that public release of performance data may slightly improve some patient outcomes (5 studies, 315,092 hospitalisations, and 7502 providers). There was low-certainty evidence from a single study to suggest that public release of performance data may have differential effects on disadvantaged populations. There was no evidence about effects on healthcare utilisation decisions by purchasers, or adverse effects.

AUTHORS' CONCLUSIONS

The existing evidence base is inadequate to directly inform policy and practice. Further studies should consider whether public release of performance data can improve patient outcomes, as well as healthcare processes.

Hospital quality reporting and improvement in quality of care for patients with acute myocardial infarction

Background

Although public reporting of hospital performance is becoming common, it remains uncertain whether public reporting leads to improvement in clinical outcomes. This study was conducted to evaluate whether enrollment in a quality reporting project is associated with improvement in quality of care for patients with acute myocardial infarction.

Methods

We conducted a quasi-experimental study using hospital census survey and national inpatient database in Japan. Hospitals enrolled in a ministry-led quality reporting project were matched with non-reporting control hospitals by one-to-one propensity score matching using hospital characteristics. Using the inpatient data of acute myocardial infarction patients hospitalized in the matched hospitals during 2011–2013, difference-in-differences analyses were conducted to evaluate the changes in unadjusted and risk-adjusted in-hospital mortality rates over time that are attributable to intervention.

Results

Matching between hospitals created a cohort of 30,220 patients with characteristics similar between the 135 reporting and 135 non-reporting hospitals. Overall in-hospital mortality rates were 13.2% in both the reporting and non-reporting hospitals. There was no significant association between hospital enrollment in the quality reporting project and change over time in unadjusted mortality (OR, 0.98; 95% CI, 0.80–1.22). In 28,168 patients eligible for evaluation of risk-adjusted mortality, enrollment was also not associated with change in risk-adjusted mortality (OR, 0.98; 95% CI, 0.81–1.17).

Conclusions

Enrollment in the quality reporting project was not associated with short-term improvement in quality of care for patients with acute myocardial infarction. Additional efforts may be necessary to improve quality of care.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3330-4) contains supplementary material, which is available to authorized users.

The effect of consultant outcome publication on surgeon behaviour: a systematic review and narrative synthesis

Introduction Surgeon-specific outcome data, or consultant outcome publication, refers to public access to named surgeon procedural outcomes. Consultant outcome publication originates from cardiothoracic surgery, having been introduced to US and UK surgery in 1991 and 2005, respectively. It has been associated with an improvement in patient outcomes. However, there is concern that it may also have led to changes in surgeon behaviour. This review assesses the literature for evidence of risk-averse behaviour, upgrading of patient risk factors and cessation of low-volume or poorly performing surgeons. Materials and methods A systematic literature review of Embase and Medline databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Original studies including data on consultant outcome publication and its potential effect on surgeon behaviour were included. Results Twenty-five studies were identified from the literature search. Studies suggesting the presence of risk-averse behaviour and upgrading of risk factors tended to be survey based, with studies contrary to these findings using recognised regional and national databases. Discussion and conclusion Our review includes instances of consultant outcome publication leading to risk-averse behaviour, upgrading of risk factors and cessation of low-volume or poorly performing surgeons. As UK data on consultant outcome publication matures, further research is essential to ensure that high-risk patients are not inappropriately turned down for surgery.

Measuring Quality for Individual Anesthesia Clinicians

A robust quality management system (QMS) will provide value to patients, providers, and hospitals or systems by focusing on system performance. The QMS must remain independent of provider-specific measures used for privileging. Some outcome measures may be used to assess system performance; they must not be used to assess individual provider performance. All anesthesia providers, especially leaders, must be guardians of an organization's safety culture.

Challenges in Outcome Reporting

Although measuring outcomes is an integral part of medical quality improvement, large-scale outcome reporting efforts face several challenges. Among these are difficulties in establishing consensus definitions for outcome measurement; classifying gray outcomes, such as postoperative respiratory failure; and adequately adjusting for patient comorbidities and severity of illness. Unintended consequences of outcome reporting can also distort care in undesirable ways, and clinician reluctance to care for high-risk patients may occur with reporting programs. Ultimately, clinicians need not compare outcomes to improve and should recognize that even outcomes that cannot be precisely quantitated can still be improved.

Lifting the veil on stroke outcomes: revisiting stroke centers' transparency through public reporting of metrics

Public reporting of healthcare metrics provides transparency that allows patients and emergency medical providers to make informed decisions about where patients should receive care. Most previous reports about public reporting of health metrics have demonstrated significant improvements in outcome metrics after implementation. However, no mechanism exists, voluntary or otherwise, for the public reporting of outcomes of stroke care. We review the components of public reporting of health outcomes data and its limited history in stroke outcomes. We summarize the literature on public reporting in cardiovascular interventions, particularly percutaneous coronary interventions, as a close corollary to mechanical neurothrombectomy. The benefits, limitations, and controversies associated with reporting of cardiovascular outcomes are reviewed with a focus on the development of risk-avoidant behaviors. This article serves as a primer for discussion of the potential benefits, limitations, and unintended consequences of public reporting of stroke data.

Incorporating Longitudinal Comorbidity and Acute Physiology Data in Template Matching for Assessing Hospital Quality: An Exploratory Study in an Integrated Health Care Delivery System

OBJECTIVE

We sought to build on the template-matching methodology by incorporating longitudinal comorbidities and acute physiology to audit hospital quality.

STUDY SETTING

Patients admitted for sepsis and pneumonia, congestive heart failure, hip fracture, and cancer between January 2010 and November 2011 at 18 Kaiser Permanente Northern California hospitals.

STUDY DESIGN

We generated a representative template of 250 patients in 4 diagnosis groups. We then matched between 1 and 5 patients at each hospital to this template using varying levels of patient information.

DATA COLLECTION

Data were collected retrospectively from inpatient and outpatient electronic records.

PRINCIPAL FINDINGS

Matching on both present-on-admission comorbidity history and physiological data significantly reduced the variation across hospitals in patient severity of illness levels compared with matching on administrative data only. After adjustment for longitudinal comorbidity and acute physiology, hospital rankings on 30-day mortality and estimates of length of stay were statistically different from rankings based on administrative data.

CONCLUSIONS

Template matching-based approaches to hospital quality assessment can be enhanced using more granular electronic medical record data.

A National Study Evaluating Hospital Volume and Inpatient Mortality after Open Abdominal Aortic Aneurysm Repair in Vulnerable Populations

BACKGROUND

There is a large body of evidence documenting better outcomes for abdominal aortic aneurysm (AAA) repairs performed in high-volume centers. However, it remains unknown if the strength of this volume-outcome relationship is moderated by race or socioeconomic status (SES).

METHODS

This is a cross-sectional retrospective cohort study evaluating 60,618 Medicare fee-for-service beneficiaries undergoing open AAA repair across 1,649 hospitals between 2005 and 2009. We selected, a priori, black race and low SES as vulnerable populations based on previous reports showing each is independently associated with higher mortality. Next, we divided hospitals into quintiles of procedural volume and used logistic regression to compare risk-adjusted rates of inpatient mortality across volume quintiles for the overall study population and separately by race (black versus nonblack) and SES (low, middle, and high).

RESULTS

Overall, patients treated in the lowest-volume hospitals (LVHs) had higher risk-adjusted inpatient mortality rates than patients treated in the highest-volume hospitals (HVHs) (15.3% vs. 10.6%, P < 0.001). Higher mortality was associated with black versus nonblack race (12.9% vs. 11.7%, P < 0.001) and low SES versus high SES (12.2% vs. 11.6% P < 0.001). While nonblack patients treated in LVHs had higher odds of mortality (versus HVHs, adjusted odds ratio (aOR) 1.83 [1.59-2.11]), this volume-outcome effect was greater for black patients (aOR 2.60 [1.63-4.16]). In contrast, high and low SES patients experienced similar differences in mortality when treated in LVHs (aOR 1.79 [1.49-2.12]; aOR 1.72 [1.28-2.30], respectively).

CONCLUSIONS

While a volume-outcome effect was observed in all patients, black patients appeared to derive a disproportionate benefit from undergoing open AAA repair in HVHs. The mechanism underlying these disparate outcomes remains unclear but warrants further evaluation of contributing hospital and patient factors.

High-Risk Percutaneous Coronary Intervention in Public Reporting States: the Evidence, Exclusion of Critically Ill Patients, and Implications

PURPOSE OF REVIEW

Public reporting of outcomes for percutaneous coronary intervention (PCI) is used in some states to drive improvements in care delivery and performance. However, a growing body of evidence suggests unintended consequences, particularly provider aversion to performing PCI in high-risk patients.

RECENT FINDINGS

There is mixed evidence regarding the impact of PCI public reporting on patient outcomes. In addition, providers in public reporting states likely have a higher threshold or potentially avoid performing PCI on high-risk patients, such as those with cardiogenic shock. The exclusion of patients with refractory cardiogenic shock from public reports in New York state has reduced provider risk aversion. Though this represents a step in the right direction, other strategies are needed to diminish continued provider risk aversion and strengthen PCI care quality. Public reporting initiatives for PCI are beginning to proliferate nationally. However, the challenge of fostering the positive of aspects of reporting, which incentivize improved care quality and procedural performance, while ensuring that high-risk patients continue to receive appropriate care remains. It is imperative that policymakers and cardiologists continue to develop innovative solutions that address risk aversive provider behaviors towards high-risk patients.

The Impact of Excluding Shock Patients on Hospital and Physician Risk-Adjusted Mortality Rates for Percutaneous Coronary Interventions: The Implications for Public Reporting

OBJECTIVES

The authors examined the impact of including shock patients in public reporting of percutaneous coronary intervention (PCI) risk-adjusted mortality.

BACKGROUND

There is concern that an unintended consequence of statewide public reporting of medical outcomes is the avoidance of appropriate interventions for high-risk patients.

METHODS

New York State's PCI registry was used to compare hospital and physician risk-adjusted mortality rates and outliers from New York's public report models with rates and outliers based on statistical models that include refractory shock patients and exclude both refractory shock and other shock patients.

RESULTS

Correlations between the public report model and each of the other 2 models were above 0.92 for hospital risk-adjusted rates and were 0.99 for all physician risk-adjusted rates (p < 0.0001). There were 11 physicians with lower than expected mortality rates (low outliers) and 41 physicians with higher than expected mortality rates (high outliers) across the 3 time periods in the public report, compared with 10 low outliers and 40 high outliers if all shock patients had been excluded. There was considerable overlap among outliers identified by the 3 models. Findings were similar for hospital outliers.

CONCLUSIONS

Risk-adjusted hospital and physician mortality rates are highly correlated regardless of whether shock patients are included in public reporting. The numbers of outliers are similar, and outlier changes are minimal, although 10% to 15% of cardiologists who were outliers in either exclusion rule were not outliers in the other one. This information can form a basis for subsequent discussions regarding the exclusion of high-risk patients from public reporting.

Predicting In-Hospital Mortality in Patients With Acute Myocardial Infarction

BACKGROUND

As a foundation for quality improvement, assessing clinical outcomes across hospitals requires appropriate risk adjustment to account for differences in patient case mix, including presentation after cardiac arrest.

OBJECTIVES

The aim of this study was to develop and validate a parsimonious patient-level clinical risk model of in-hospital mortality for contemporary patients with acute myocardial infarction.

METHODS

Patient characteristics at the time of presentation in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-GWTG (Get With the Guidelines) database from January 2012 through December 2013 were used to develop a multivariate hierarchical logistic regression model predicting in-hospital mortality. The population (243,440 patients from 655 hospitals) was divided into a 60% sample for model derivation, with the remaining 40% used for model validation. A simplified risk score was created to enable prospective risk stratification in clinical care.

RESULTS

The in-hospital mortality rate was 4.6%. Age, heart rate, systolic blood pressure, presentation after cardiac arrest, presentation in cardiogenic shock, presentation in heart failure, presentation with ST-segment elevation myocardial infarction, creatinine clearance, and troponin ratio were all independently associated with in-hospital mortality. The C statistic was 0.88, with good calibration. The model performed well in subgroups based on age; sex; race; transfer status; and the presence of diabetes mellitus, renal dysfunction, cardiac arrest, cardiogenic shock, and ST-segment elevation myocardial infarction. Observed mortality rates varied substantially across risk groups, ranging from 0.4% in the lowest risk group (score <30) to 49.5% in the highest risk group (score >59).

CONCLUSIONS

This parsimonious risk model for in-hospital mortality is a valid instrument for risk adjustment and risk stratification in contemporary patients with acute myocardial infarction.

Cardiovascular Disease Prevention: The Role of Policy Interventions

OPINION STATEMENT

Health outcomes in cardiovascular disease in the USA have generally been improving over the past several decades. Those gains have been related to both developments in prevention and treatment of cardiovascular disease. To further enhance improvement in health outcomes, including cardiovascular outcomes, health policies have been implemented to incentivize prevention. These policies have strong conceptual appeal and have been associated with improvements in some health metrics. However, robust research methods, accounting for bias and statistical confounding, are critical to confirm that these policies are associated with prevention of cardiovascular events for patients over time.

Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care

Background

The feedback of patient-reported outcome measures (PROMs) data is intended to support the care of individual patients and to act as a quality improvement (QI) strategy.

Objectives

To (1) identify the ideas and assumptions underlying how individual and aggregated PROMs data are intended to improve patient care, and (2) review the evidence to examine the circumstances in which and processes through which PROMs feedback improves patient care.

Design

Two separate but related realist syntheses: (1) feedback of aggregate PROMs and performance data to improve patient care, and (2) feedback of individual PROMs data to improve patient care.

Interventions

Aggregate – feedback and public reporting of PROMs, patient experience data and performance data to hospital providers and primary care organisations. Individual – feedback of PROMs in oncology, palliative care and the care of people with mental health problems in primary and secondary care settings.

Main outcome measures

Aggregate – providers’ responses, attitudes and experiences of using PROMs and performance data to improve patient care. Individual – providers’ and patients’ experiences of using PROMs data to raise issues with clinicians, change clinicians’ communication practices, change patient management and improve patient well-being.

Data sources

Searches of electronic databases and forwards and backwards citation tracking.

Review methods

Realist synthesis to identify, test and refine programme theories about when, how and why PROMs feedback leads to improvements in patient care.

Results

Providers were more likely to take steps to improve patient care in response to the feedback and public reporting of aggregate PROMs and performance data if they perceived that these data were credible, were aimed at improving patient care, and were timely and provided a clear indication of the source of the problem. However, implementing substantial and sustainable improvement to patient care required system-wide approaches. In the care of individual patients, PROMs function more as a tool to support patients in raising issues with clinicians than they do in substantially changing clinicians’ communication practices with patients. Patients valued both standardised and individualised PROMs as a tool to raise issues, but thought is required as to which patients may benefit and which may not. In settings such as palliative care and psychotherapy, clinicians viewed individualised PROMs as useful to build rapport and support the therapeutic process. PROMs feedback did not substantially shift clinicians’ communication practices or focus discussion on psychosocial issues; this required a shift in clinicians’ perceptions of their remit.

Strengths and limitations

There was a paucity of research examining the feedback of aggregate PROMs data to providers, and we drew on evidence from interventions with similar programme theories (other forms of performance data) to test our theories.

Conclusions

PROMs data act as ‘tin openers’ rather than ‘dials’. Providers need more support and guidance on how to collect their own internal data, how to rule out alternative explanations for their outlier status and how to explore the possible causes of their outlier status. There is also tension between PROMs as a QI strategy versus their use in the care of individual patients; PROMs that clinicians find useful in assessing patients, such as individualised measures, are not useful as indicators of service quality.

Future work

Future research should (1) explore how differently performing providers have responded to aggregate PROMs feedback, and how organisations have collected PROMs data both for individual patient care and to improve service quality; and (2) explore whether or not and how incorporating PROMs into patients’ electronic records allows multiple different clinicians to receive PROMs feedback, discuss it with patients and act on the data to improve patient care.

Study registration

This study is registered as PROSPERO CRD42013005938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Management Strategies and Outcomes of ST-Segment Elevation Myocardial Infarction Patients Transferred After Receiving Fibrinolytic Therapy in the United States

Fibrinolytic therapy is still used in patients with ST-segment elevation myocardial infarction (STEMI) when the primary percutaneous coronary intervention cannot be provided in a timely fashion. Management strategies and outcomes in transferred fibrinolytic-treated STEMI patients have not been well assessed in real-world settings. Using the Nationwide Inpatient Sample from 2008 to 2012, we identified 18 814 patients with STEMI who received fibrinolytic therapy and were transferred to a different facility within 24 hours. The primary outcome was in-hospital mortality. Secondary outcomes included gastrointestinal bleeding, bleeding requiring transfusion, intracranial hemorrhage (ICH), length of stay, and cost. The patients were divided into 3 groups: those who received medical therapy alone (n = 853; 4.5%), those who underwent coronary artery angiography without revascularization (n = 2573; 13.7%), and those who underwent coronary artery angiography with revascularization (n = 15 388; 81.8%). Rates of in-hospital mortality among the groups were 20% vs 6.6% vs 2.1%, respectively (P < 0.001); ICH was 8.5% vs 1.1% vs 0.6%, respectively (P < 0.001); and gastrointestinal bleeding was 1.1% vs 0.4% vs 0.4%, respectively (P = 0.011). Multivariate analysis identified increasing age, higher Charlson Comorbidity Index score, cardiogenic shock, cardiac arrest, and ICH as the independent predictors of not performing coronary artery angiography and/or revascularization in patients with STEMI initially treated with fibrinolytic therapy. The majority of STEMI patients transferred after receiving fibrinolytic therapy undergo coronary angiography. However, notable numbers of patients do not receive revascularization, especially patients with cardiogenic shock and following a cardiac arrest.

The effect of high-risk ST elevation myocardial infarction transfer patients on risk-adjusted in-hospital mortality: A report from the American Heart Association Mission: Lifeline program

BACKGROUND

Hospital mortality is an important quality measure for acute myocardial infarction care. There is a concern that despite risk adjustment, percutaneous coronary intervention hospitals accepting a greater volume of high-risk ST elevation myocardial infarction (STEMI) transfer patients may have their reported mortality rates adversely affected.

METHODS

The STEMI patients in the National Cardiovascular Data RegistryAcute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines from April 2011 to December 2013 were included. High-risk STEMI was defined as having either cardiogenic shock or cardiac arrest on first medical contact. Receiving hospitals were divided into tertiles based on the ratio of high-risk STEMI transfer patients to the total number of STEMI patients treated at each hospital. Using the Action Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines in-hospital mortality risk model, we calculated the difference in risk-standardized in-hospital mortality before and after excluding high-risk STEMI transfers in each tertile.

RESULTS

Among 119,680 STEMI patients treated at 539 receiving hospitals, 37,028 (31%) were transfer patients, of whom 4,500 (12%) were highrisk. The proportion of high-risk STEMI transfer patients ranged from 0% to 12% across hospitals. Unadjusted mortality rates in the low-, middle-, and high-tertile hospitals were 6.0%, 6.0%, and 5.9% among all STEMI patients and 6.0%, 5.5%, and 4.6% after excluding high-risk STEMI transfers. However, risk-standardized hospital mortality rates were not significantly changed after excluding high-risk STEMI transfer patients in any of the 3 hospital tertiles (low, -0.04%; middle, -0.05%; and high, 0.03%).

CONCLUSIONS

Risk-adjusted in-hospital mortality rates were not adversely affected in STEMI-receiving hospitals who accepted more high-risk STEMI transfer patients when a clinical mortality risk model was used for risk adjustment.

Do Health Care Providers Use Online Patient Ratings to Improve the Quality of Care? Results From an Online-Based Cross-Sectional Study

Background

Physician-rating websites have become a popular tool to create more transparency about the quality of health care providers. So far, it remains unknown whether online-based rating websites have the potential to contribute to a better standard of care.

Objective

Our goal was to examine which health care providers use online rating websites and for what purposes, and whether health care providers use online patient ratings to improve patient care.

Methods

We conducted an online-based cross-sectional study by surveying 2360 physicians and other health care providers (September 2015). In addition to descriptive statistics, we performed multilevel logistic regression models to ascertain the effects of providers’ demographics as well as report card-related variables on the likelihood that providers implement measures to improve patient care.

Results

Overall, more than half of the responding providers surveyed (54.66%, 1290/2360) used online ratings to derive measures to improve patient care (implemented measures: mean 3.06, SD 2.29). Ophthalmologists (68%, 40/59) and gynecologists (65.4%, 123/188) were most likely to implement any measures. The most widely implemented quality measures were related to communication with patients (28.77%, 679/2360), the appointment scheduling process (23.60%, 557/2360), and office workflow (21.23%, 501/2360). Scaled-survey results had a greater impact on deriving measures than narrative comments. Multilevel logistic regression models revealed medical specialty, the frequency of report card use, and the appraisal of the trustworthiness of scaled-survey ratings to be significantly associated predictors for implementing measures to improve patient care because of online ratings.

Conclusions

Our results suggest that online ratings displayed on physician-rating websites have an impact on patient care. Despite the limitations of our study and unintended consequences of physician-rating websites, they still may have the potential to improve patient care.

Do Cardiac Surgery Report Cards Reduce Mortality? Assessing the Evidence

Provider report cards feature prominently in ongoing efforts to improve patient quality. A well-known example is the cardiac surgery report-card program started in New York, which publicly compares hospital and surgeon performance. Public report cards have been associated with decreases in cardiac surgery mortality, but there is substantial disagreement over the source(s) of the improvement. This article develops a conceptual framework to explain how report-card-related responses could result in lower mortality and reviews the evidence. Existing research shows that report cards have not greatly changed referral patterns. How much providers increased their quality of care and altered their selection of patients remains unresolved, and alternative explanations have not been well studied. Future research should expand the number of states and years covered and exploit the variation in institutional features to improve our understanding of the relationship between report cards and outcomes.

The impact of Public Reporting on clinical outcomes: a systematic review and meta-analysis

Background

To assess both qualitatively and quantitatively the impact of Public Reporting (PR) on clinical outcomes, we carried out a systematic review of published studies on this topic.

Methods

Pubmed, Web of Science and SCOPUS databases were searched to identify studies published from 1991 to 2014 that investigated the relationship between PR and clinical outcomes. Studies were considered eligible if they investigated the relationship between PR and clinical outcomes and comprehensively described the PR mechanism and the study design adopted. Among the clinical outcomes identified, meta-analysis was performed for overall mortality rate which quantitative data were exhaustively reported in a sufficient number of studies. Two reviewers conducted all data extraction independently and disagreements were resolved through discussion. The same reviewers evaluated also the quality of the studies using a GRADE approach.

Results

Twenty-seven studies were included. Mainly, the effect of PR on clinical outcomes was positive. Meta-analysis regarding overall mortality included, in a context of high heterogeneity, 10 studies with a total of 1,840,401 experimental events and 3,670,446 control events and resulted in a RR of 0.85 (95 % CI, 0.79-0.92).

Conclusions

The introduction of PR programs at different levels of the healthcare sector is a challenging but rewarding public health strategy. Existing research covering different clinical outcomes supports the idea that PR could, in fact, stimulate providers to improve healthcare quality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1543-y) contains supplementary material, which is available to authorized users.

Public reporting and coronary revascularization: risk and benefit

Since the 1980s, the evolution of public reporting of provider-specific and institution-specific clinical outcomes has historically been rooted in the field of cardiology. Although public reporting is not a novel concept, how we collect, analyze, report, and interpret outcome data remains a critical element in quality improvement and in the quest toward providing truly high-value care. In this review, we explore the emergence of public reporting within the scope of cardiovascular medicine, specifically as it relates to surgical and percutaneous coronary revascularization. We highlight both the advantages and the disadvantages of public reporting from the perspective of the patient, the practicing physician, the hospital, and the healthcare system. A discussion on the limitations of public reporting and specific strategies by which it can be improved is presented.

A contemporary risk model for predicting 30-day mortality following percutaneous coronary intervention in England and Wales

BACKGROUND

The current risk model for percutaneous coronary intervention (PCI) in the UK is based on outcomes of patients treated in a different era of interventional cardiology. This study aimed to create a new model, based on a contemporary cohort of PCI treated patients, which would: predict 30 day mortality; provide good discrimination; and be well calibrated across a broad risk-spectrum.

METHODS AND RESULTS

The model was derived from a training dataset of 336,433 PCI cases carried out between 2007 and 2011 in England and Wales, with 30 day mortality provided by record linkage. Candidate variables were selected on the basis of clinical consensus and data quality. Procedures in 2012 were used to perform temporal validation of the model. The strongest predictors of 30-day mortality were: cardiogenic shock; dialysis; and the indication for PCI and the degree of urgency with which it was performed. The model had an area under the receiver operator characteristic curve of 0.85 on the training data and 0.86 on validation. Calibration plots indicated a good model fit on development which was maintained on validation.

CONCLUSION

We have created a contemporary model for PCI that encompasses a range of clinical risk, from stable elective PCI to emergency primary PCI and cardiogenic shock. The model is easy to apply and based on data reported in national registries. It has a high degree of discrimination and is well calibrated across the risk spectrum. The examination of key outcomes in PCI audit can be improved with this risk-adjusted model.

Collaborative quality improvement vs public reporting for percutaneous coronary intervention: A comparison of percutaneous coronary intervention in New York vs Michigan

INTRODUCTION

Public reporting (PR) is a policy mechanism that may improve clinical outcomes for percutaneous coronary intervention (PCI). However, prior studies have shown that PR may have an adverse impact on patient selection. It is unclear whether alternatives to PR, such as collaborative quality improvement (CQI), may drive improvements in quality of care and outcomes for patients receiving PCI without the unintended consequences seen with PR.

METHODS

Using National Cardiovascular Data Registry CathPCI Registry data from January 2011 through September 2012, we evaluated patients who underwent PCI in New York (NY), a state with PR (N = 51,983), to Michigan, a state with CQI (N = 53,528). We compared patient characteristics, the quality of care delivered, and clinical outcomes.

RESULTS

Patients undergoing PCI in NY had a lower-risk profile, with a lower proportion of patients with ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, or cardiogenic shock, compared with Michigan. Quality of care was broadly similar in the 2 states; however, outcomes were better in NY. In a propensity-matched analysis, patients in NY were less likely to be referred for emergent, urgent, or salvage coronary artery bypass surgery (odds ratio [OR] 0.67, 95% CI 0.51-0.88, P < .0001) and to receive blood transfusion (OR 0.7, 95% CI 0.61-0.82, P < .0001), and had lower in-hospital mortality (OR 0.72, 95% CI 0.63-0.83, P < .0001).

CONCLUSIONS

Public reporting of PCI data is associated with fewer high-risk patients undergoing PCI compared with CQI. However, in comparable samples of patients, PR is also associated with a lower risk of mortality and adverse events. The optimal quality improvement method may involve combining these 2 strategies to protect access to care while still driving improvements in patient outcomes.

State mandated public reporting and outcomes of percutaneous coronary intervention in the United States

Public reporting has been proposed as a strategy to improve health care quality. Percutaneous coronary interventions (PCIs) performed in the United States from July 1, 2009, to June 30, 2011, included in the CathPCI Registry were identified (n = 1,340,213). Patient characteristics and predicted and observed in-hospital mortality were compared between patients treated with PCI in states with mandated public reporting (Massachusetts, New York, Pennsylvania) and states without mandated public reporting. Most PCIs occurred in states without mandatory public reporting (88%, n = 1,184,544). Relative to patients treated in nonpublic reporting states, those who underwent PCI in public reporting states had similar predicted in-hospital mortality (1.39% vs 1.37%, p = 0.17) but lower observed in-hospital mortality (1.19% vs 1.41%, adjusted odds ratio [ORadj] 0.80; 95% confidence interval [CI] 0.74, 0.88; p <0.001). In patients for whom outcomes were available at 180 days, the differences in mortality persisted (4.6% vs 5.4%, ORadj 0.85, 95% CI 0.79 to 0.92, p <0.001), whereas there was no difference in myocardial infarction (ORadj 0.97, 95% CI 0.89 to 1.07) or revascularization (ORadj 1.05, 95% CI 0.92 to 1.20). Hospital readmissions were increased at 180 days in patients who underwent PCI in public reporting states (ORadj 1.08, 95% CI 1.03 to 1.12, p = 0.001). In conclusion, patients who underwent PCI in states with mandated public reporting of outcomes had similar predicted risks but significantly lower observed risks of death during hospitalization and in the 6 months after PCI. These findings support considering public reporting as a potential strategy for improving outcomes of patients who underwent PCI although further studies are warranted to delineate the reasons for these differences.

Association between public reporting of outcomes with procedural management and mortality for patients with acute myocardial infarction

BACKGROUND

Public reporting of procedural outcomes may create disincentives to provide percutaneous coronary intervention (PCI) for critically ill patients.

OBJECTIVES

This study evaluated the association between public reporting with procedural management and outcomes among patients with acute myocardial infarction (AMI).

METHODS

Using the Nationwide Inpatient Sample, we identified all patients with a primary diagnosis of AMI in states with public reporting (Massachusetts and New York) and regionally comparable states without public reporting (Connecticut, Maine, Maryland, New Hampshire, Rhode Island, and Vermont) between 2005 and 2011. Procedural management and in-hospital outcomes were stratified by public reporting.

RESULTS

Among 84,121 patients hospitalized with AMI, 57,629 (69%) underwent treatment in a public reporting state. After multivariate adjustment, percutaneous revascularization was performed less often in public reporting states than in nonreporting states (odds ratio [OR]: 0.81, 95% confidence interval [CI]: 0.67 to 0.96), especially among older patients (OR: 0.75, 95% CI: 0.62 to 0.91), those with Medicare insurance (OR: 0.75, 95% CI: 0.62 to 0.91), and those presenting with ST-segment elevation myocardial infarction (OR: 0.63, 95% CI: 0.56 to 0.71) or concomitant cardiac arrest or cardiogenic shock (OR: 0.58, 95% CI: 0.47 to 0.70). Overall, patients with AMI in public reporting states had higher adjusted in-hospital mortality rates (OR: 1.21, 95% CI: 1.06 to 1.37) than those in nonreporting states. This was observed predominantly in patients who did not receive percutaneous revascularization in public reporting states (adjusted OR: 1.30, 95% CI: 1.13 to 1.50), whereas those undergoing the procedure had lower mortality (OR: 0.71, 95% CI: 0.62 to 0.83).

CONCLUSIONS

Public reporting is associated with reduced percutaneous revascularization and increased in-hospital mortality among patients with AMI, particularly among patients not selected for PCI.