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

Abstract

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.

Keywords: acute coronary syndromes(s); percutaneous coronary intervention; public reporting.

Figure 1. Rate of In-Hospital Mortality for Acute Myocardial Infarction Stratified by Public Reporting and Percutaneous Coronary Intervention, 2005 – 2011

The adjusted odds of mortality was significantly lower in public reporting states among myocardial infarction patients undergoing intervention but significantly higher in public reporting states for patients that did not undergo percutaneous revascularization (interaction p < 0.001).

Central Illustration. Public Reporting and Percutaneous Coronary Intervention for Acute Myocardial Infarction (AMI): Rates of Percutaneous Intervention and In-Hospital Mortality for AMI, 2005 – 2011

Upper Panel: The adjusted odds of undergoing percutaneous revascularization among patients with acute myocardial infarction (AMI) was significantly lower in public reporting states compared to non-reporting states (p = 0.017). These findings were specifically pronounced among patients with older age, those with Medicare insurance and those presenting with STEMI or concomitant cardiac arrest or cardiogenic shock (interaction p < 0.001 for each comparison). Lower Panel: The adjusted odds of in-hospital mortality among patients with acute myocardial infarction were significantly higher in public reporting states compared to non-reporting states (p = 0.003). This finding was consistent across all ages and insurance carriers though slightly more prominent among those with a non-ST elevation myocardial infarction (interaction p = 0.035).