Coronary Care Survey Finds Certain Public Health Hazards

Ruzanna Harutyunyan's picture
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Recently, Massachusetts joined the growing number of states in publicly reporting mortality and risks associated with treatment for interventional cardiac care, such as being treated for a heart attack with a stent, coronary artery by-pass surgery (CABG) and other procedures. The public’s right to know about the quality of care they can receive and the creation of transparency between health care providers and patients is a positive initiative. In states where public reporting is in place, such as Massachusetts and New York, significant declines in mortality rates have been reported.

Brigham and Women’s Hospital (BWH) interventional cardiologists Dr. Frederic Resnic and Dr. Frederick Welt analyzed current reporting criteria and found that potential risks of public reporting of clinical outcomes may lead some care givers to be more conservative in treating, or not, the sickest patients who stand to gain the most. The study appeared in the Journal of the American College of Cardiology.

In an analysis of interventional coronary procedures at BWH between 2003 and 2005 (the first year of public reporting), Drs. Resnic and Welt found that nearly 45 percent of patients who died prior to being discharged from the hospital had at least one severe, acute medical condition before treatment that was not accounted for in the data collection methods used by the state mandated initiative. Examples of acute severe conditions included stroke, active infection, post-operative heart attack following major non-cardiac surgery among others.

By further analyzing and classifying the deaths and adding pre-procedural information, such as presenting with a neurologic compromise following a heart attack, history of malignancy, in-hospital acute coronary syndrome following non-cardiac surgery and admittance to the hospital with an existing infection, the doctors were able to do a “before and after” comparison of the reporting and found modest improvement. This finding suggests that expanding the existing risk prediction methods would provide a more accurate picture for outcomes among patients with a co-existing medical condition who need interventional cardiac care.

Comparing the results that Resnic and Welt found at BWH to data from New York shows that deaths following interventional coronary procedures had decreased by 36 percent between 1996 and 2003 in New York State.

However, the doctors found a trend toward the avoidance of performing cardiac procedures on higher risk patients in NY, with a 30 percent decline over a six year period in patients presenting with cardiogenic shock, a severely decreased ability of the heart to pump blood throughout the body, sending a patient into shock. Similar declines were also found in Massachusetts.

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“Public reporting of risk-adjustment outcomes for patients being treated for emergency heart attacks, who also may have a co-existing and serious medical condition, is an important tool to ensure quality improvement and transparency,” said Dr. Frederick Resnic, director of the Cardiac Catheterization Lab at BWH.

“The risk currently is that it could lead to changes in patient selection by physicians who do not trust that the risk- adjustment is accurate for the highest risk patients. This leads to a gradual erosion in the willingness of doctors to treat the sickest and most complex patients; despite the fact that these patients have the most to gain from a heart procedure.”

Drs. Resnic and Welt recommend a four point strategy to help improve public reporting outcomes.

* Address the underlying incentives for “case-selection creep” by improving risk adjustment methods for the highest risk patients and by highlighting centers and physicians who undertake high-risk procedures in appropriate patients.

* Provide adequate resources for assuring high quality data collection and analysis efforts as part of any mandated outcomes reporting effort.

* Develop national standards for public reporting of risk adjusted clinical outcomes

* Develop and report measures of appropriateness to complement risk adjusted outcomes in public reporting programs.

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