• With End of Public Reporting, Better Tx of Cardiogenic Shock in NY Did reporting compromise care by increasing risk aversion?

    A move away from publicly reporting centers’ mortality rates in myocardial infarction (MI) complicated by cardiogenic shock in New York state was associated with substantial increases in invasive management as well as better outcomes, two studies found.

    Invasive treatments became more common in the state as cases of cardiogenic shock went from being publicly reported (2002-2005) to selectively reported (2006-2007) to non-publicly reported (2008-present), as Sripal Bangalore, MD, MHA, of New York University School of Medicine, and colleagues reported online in JAMA Cardiology, included:

    • Percutaneous coronary intervention (PCI; 31.1% versus 39.8% versus 40.7% across the three periods, odds ratio 1.50, 95% CI 1.12 to 2.01)
    • Cardiac catheterization, PCI, or coronary artery bypass graft (CABG; 59.7% versus 70.9% versus 73.8%, OR 1.84, 95% CI 1.37 to 2.47)
    • PCI or CABG (43.1% versus 55.9% versus 56.3%, OR 1.66, 95% CI 1.26 to 2.20)

    Michigan, a state without public reporting, paralleled these upwards trends across the same time periods but at even higher rates:

    • PCI (41.2% versus 52.6% versus 57.8%, OR 1.93, 95% CI 1.45 to 2.56)
    • Cardiac catheterization, PCI, or CABG (64.4% versus 80.5% versus 78.6%, OR 2.01, 95% CI 1.47 to 2.74)
    • PCI or CABG (51.2% versus 65.8% versus 68.0%, OR 2.00, 95% CI 1.50 to 2.66)

    These findings were echoed in patients in California and New Jersey, two other states that consistently did not report. Lagging invasive management in New York despite the 2006 policy switch may be attributed to the strict rules for exemption from public reporting in that state, Bangalore’s group suggested. Nonetheless, it is “yet to be determined” if a loosening of the criteria would improve access to care, they acknowledged.

    More cardiogenic shock patients survived to discharge ever since New York stopped public reporting, a separate study in the same journal found.

    PCI referrals soared in the state after the switch in its public reporting policy (adjusted relative risk [RR] 1.28, 95% CI 1.19 to 1.37), more so than for their peers in non-reporting states during the same period (adjusted RR 1.09, 95% CI 1.05 to 1.13).

    Moreover, in-hospital death after acute myocardial infarction coupled with cardiogenic shock fell more drastically in New York (adjusted RR 0.76, 95% CI 0.72 to 0.81) than in other states (adjusted RR 0.91, 95% CI 0.87 to 0.94), according to Robert W. Yeh, MD, MSc, of Boston’s Beth Israel Deaconess Medical Center, and colleagues.

    “The present analysis suggests that the censoring of adjudicated, extreme-risk cases may have been effective at facilitating guideline-directed revascularization and improving outcomes,” the investigators concluded.

    Nevertheless, like the Bangalore study, Yeh’s group also reported that PCI in New York did not manage to catch up to the consistently non-reporting states, which indicate “continued risk aversion on the part of PCI operators in a public reporting environment.”

    The damage was already done, suggested Ajay J. Kirtane, MD, SM, of Columbia University Medical Center/New York-Presbyterian Hospital, and colleagues in an accompanying editorial.

    “Even with the recognition that risk adjustment was not enough to mitigate risk aversion, which led to the New York shock exclusion in 2006, this policy change — although perhaps helpful — still did not do enough to encourage physicians to care for the sickest patients who had the most to lose,” they wrote in an editorial.

    “These findings should therefore give pause for those who advocate more widespread and indiscriminate public reporting of PCI mortality without careful consideration of the consequences. It may simply be time to recognize that mortality following PCI is the wrong metric with which to arbitrate its quality across heterogeneous patient scenarios, despite attempts to separate these scenarios into discrete entities, such as shock and nonshock.”

    As an alternative to public reporting, Kirtane suggested collaborative efforts contained to providers and institutions and reporting process-related rather than outcome-related data to the public.

    Yeh’s study gathered data from statewide databases in Massachusetts, Michigan, New Jersey, and New York (n=45,977). In addition to the inherent limitations of a retrospective study, it was also limited by an incomplete dataset such that comorbidities and other confounders were not fully accounted for.

    Bangalore and colleagues’ analysis consisted of patients (n=2,2126) from the National Inpatient Sample who were admitted for MI complicated by cardiogenic shock. Data was matched by propensity score between New York patients and those in the non-reporting states.

    Such a study carries the potential for miscoding in the administrative database, Bangalore and colleagues wrote. There is also the possibility of cases being upcoded to be exempt from public reporting.



    Bangalore and Yeh reported no relevant conflicts of interest.

    Kirtane disclosed institutional research grants from Medtronic, Boston Scientific, Abiomed, Abbott Vascular, St. Jude Medical, Eli Lilly, and GlaxoSmithKline.


    JAMA Cardiology


    Bangalore S, et al “Rates of invasive management of cardiogenic shock in New York before and after exclusion from public reporting” JAMA Cardiol 2016; DOI: 10.1001/jamacardio.2016.0785.


    JAMA Cardiology


    McCabe JM, et al “Treatment and outcomes of acute myocardial infarction complicated by shock after public reporting policy changes in New York” JAMA Cardiol 2016; DOI: 10.1001/jamacardio.2016.1806.


    JAMA Cardiology


    Kirtane AJ, et al “The complicated calculus of publicly reporting mortality after percutaneous coronary intervention” JAMA Cardiol 2016; DOI: 10.1001/jamacardio.2016.1207.

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