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Revealing Angioplasty Outcomes Didn’t Improve Patient Mortality: Study

By Jordan Rau

October 9th, 2012, 4:21 PM

In the 23 years since New York State began publishing hospital death rates of coronary artery-bypass graft patients, the number of publicly reported outcome measures has proliferated. There are now 258 public reports on health care quality available around the country, according to the Robert Wood Johnson Foundation.

Researchers are still studying what impact this transparency movement has had. The latest such effort, published Tuesday by the Journal of the American Medical Association, looked at three states that publicly report the results of heart attack patients receiving angioplasties, stents and other percutaneous coronary interventions (PCIs).

The study compared the utilization rates and outcomes of PCI in those states — New York, Pennsylvania and Massachusetts — with a control group of neighboring states that don’t: Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland and Delaware. The researchers found no difference in the rates of PCI patient mortality between the transparency states and the control states.

But they did find that states that publicly reported their PCI rates tended to do fewer of them, particularly for the sickest patients — who are those most likely to die. In Massachusetts, the drop in PCI rates began after the state began publishing the information in 2005. (The study didn’t look at the before and after rates in New York and Pennsylvania, because public reporting has been going on for more than a decade in both places.)

The paper surmises two possible causes for why public reporting is associated with lower rates of PCI:

“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 because of concern over the risk of poor outcomes. Although policy makers 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 comorbid conditions of their own patient population.”

Dr. Karen Joynt, a Boston cardiologist and the study’s lead author, said the lesson is that “if we’re going to do transparency, we ought to figure out how to do it right.” Among the needed improvements, she said, are that “we need to do a better job with the risk adjustment so that hospitals that take care of really, really sick patients feel they get credit for doing so.”

jrau@kff.org

4 Responses to “Revealing Angioplasty Outcomes Didn’t Improve Patient Mortality: Study”

  1. There is strong and disturbing evidence that PCI is often performed unnecessarily, so it seems to me reducing the incidence of these procedures may well be a positive. Indeed, the takehome message of this study seems to be the potential for transparency to reduce overuse. That would have a transformative impact on our health care system.

    I don’t think this study says much of interest about whether transparency impacts outcomes or vice-versa. PCI is not the best procedure to study, since death rates from PCI are extremely low. Public reporting can drive change when it helps consumersdiscern among providers, and so it needs to show variation in performance. There can hardly be variation in mortality rates among providers when 99% of the time the patient survives.

  2. JD Graham says:

    The assertion that “Public reporting can drive change when it helps consumers discern among providers…” is in correct to apply to medical care. It’s an idea promoted during an epoch of market-driven medical care characterized by profit-seeking, without improving outcomes.

    Medical care is not a consumer commodity in the manner of ipods or breakfast cereal. People do not consumer-shop while they have rectal bleeding or chest pain. See for example the INefficacy of consumer report-cards in medical care, as reviewed in a robust data set in Fung et al Ann Intern Med, 2008.

    That “PCI is not the best procedure to study” suggests that other procedures would be more appropriate to somehow demonstrate that consumer reporting will change mortality. The only “medical” services likely to respond to market-consumer terms cosmetic-type luxury care. Sick patients are not empowered as consumers. Efforts to improve their consumerism distracts from more important, but more difficult, public policy integrity.

  3. JD Graham says:

    The assertion that “Public reporting can drive change when it helps consumers discern among providers…” is in correct to apply to medical care. It’s an idea promoted during an epoch of market-driven medical care characterized by profit-seeking, without improving outcomes.

    Medical care is not a consumer commodity in the manner of ipods or breakfast cereal. People do not consumer-shop while they have rectal bleeding or chest pain. See for example the INefficacy of consumer report-cards in medical care, as reviewed in a robust data set in Fung et al Ann Intern Med, 2008.

    That “PCI is not the best procedure to study” suggests that other procedures would be more appropriate to somehow demonstrate that consumer reporting will change mortality. The only “medical” services likely to respond to market-consumer terms are cosmetic-type luxury care. Sick patients are not empowered as consumers. Efforts to improve their consumerism distracts from more important, but more difficult, public policy integrity.

  4. ML Moseley says:

    Transparency is here to stay, but, as Dr. Joynt states, we need to get it right. PCI mortality isn’t the main concern. What are significant complications? What are the long-term outcomes of PCI, especially as compared to CABG surgery? Who are the audiences we are trying to educate? We cannot get transparency right until we ask the right questions.

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