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

Abstract

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.

Keywords: Acute myocardial infarction; Cardiogenic shock; Percutaneous coronary intervention; Public reporting.

Figure 1

Adjusted Relative Risk (aRR) of Percutaneous Coronary Intervention (left) and In-Hospital Mortality (right) for Patients with Cardiogenic Shock per Year Compared with Non-New York States in 2002. Used with permission from American Medical Association. * Error bars indicate 95% confidence intervals