Monitoring the Quality of Invasive Cardiac Services: The Unintended Consequences of Public Reporting Frederic S. Resnic, MD MSc, FACC Brigham and Women’s.

Monitoring the Quality of Invasive Cardiac Services:

The Unintended Consequences of Public Reporting

Frederic S. Resnic, MD MSc, FACCBrigham and Women’s Hospital andHarvard Medical School

March, 2010

BrighamandWomen’sHospital Case Summary

• Mr. H. is an active 67 year old, with history of hypertension, coronary artery disease and dilated cardiomyopathy, who presented in acute pulmonary edema to an outside hospital. He had previously refused coronary angiography.

• On presentation, patient was profoundly hypotensive and dyspneic and required mechanical ventilation and support with multiple vas0-pressor agents

• Urgent catheterization revealed left main with severe three vessel CAD and a thrombotic (acute) lesion in right coronary artery. PCWP=38, pH=7.09

• Underwent successful emergent PCI of RCA with IABP support. Echo demonstrated EF=15% with global hypokinesis and inferior AK.

BrighamandWomen’sHospital Case Summary

• Transferred to BWH CCU for urgent consideration of CABG.

• Unable to wean IABP; continued pressor dependence, worsening O2 requirements, worsening renal function.

• Deemed not surgical candidate by two staff cardiac surgeons due to excessively high perioperative risk.

• Family sought “everything that can be done”

• Referred for high risk PCI of unprotected left main coronary artery, LAD and LCx to potentially allow wean from IABP and pressor support.

BrighamandWomen’sHospital


BrighamandWomen’sHospital Hospital Course

• Remained on pVAD support for 5 days with reduced vasopressor requirements.

• Myocardial function stabilized enough for pVAD to be removed; however continued pressor dependent and CVVH required for volume balance.

• Progressive multi-system organ failure with ARF, ARDS and progressive liver failure. No clear neurologic recovery despite weaning all sedation.

• Ultimately, patient made comfort measures only and expired peacefully on hospital day 20.

Issues RaisedBrighamandWomen’sHospital

OverviewBrighamandWomen’sHospital

• Defining “Quality” in Cardiac Surgery and Angioplasty

• Benefits and risks of public release of individual quality monitoring results

• Evidence for unintended consequences

• Strategies for a more comprehensive approach to quality monitoring

Interpreting Mass-DAC ReportsBrighamandWomen’sHospital

Source: 2006 PCI in MA – www.massdac.org

Mass-DAC uses “Standardized Mortality Incidence Rates” (SMIR) to compare hospital risk adjusted in-hospital all-cause mortality as a measure of overall quality.

2008 No Shock and No STEMI Risk Model



2008: No Shock and No STEMIBrighamandWomen’sHospital


2008 results indicate all centers performed within expectations.

2008 Shock or STEMI Risk ModelBrighamandWomen’sHospital


2008 Results: Shock or STEMIBrighamandWomen’sHospital


Again, no institutions identified as statistical outliers….

Cardiac Quality: The Big PictureBrighamandWomen’sHospital

ClinicalOutcomes

ProcessMeasures

Appropriateness

Access toHealthcare


ProcessMeasures

Appropriateness

Access toHealthcare

ClinicalOutcomes

Benefits Risks

• Promotes Informed Consumer Choice

• Hawthorne Effect

• “Teeth” for Quality Monitoring

• Accelerates Adoption of Best Practices

• Transparency

BrighamandWomen’sHospital Trade-Off’s in Public Reporting

Benefits Risks





• Transparency


Outcomes Trends in MABrighamandWomen’sHospital

Adapted from www.MassDac.org cardiac surgery and PCI reports 2002-2005

Unadjusted mortality has declined for both CABG and PCI treated patients in Massachusetts.

http://www.massdac.org/

Volume and Mortality Trends 2003-2007BrighamandWomen’sHospital


Statewide results indicate a 7.5% per year reduction in elective (non Shock or STEMI) volume since 2003.

Continued reduction in mortality of high risk group may indicate growing risk aversion by PCI operators.

Benefits Risks





• Transparency


• Over-emphasis on MD

• Emphasis on Low Risk Cases

• Risk Avoidance of High Risk Cases

• Up-coding and Gaming

• Unmeasured Quality Parameters Ignored

NY State PCI Mortality TrendsBrighamandWomen’sHospital

Adapted from: Annual Angioplasty Quality Reports 1997-2004 available from: www.health.state.ny.us/statistics/diseases/cardiovascular/

In-hospital mortality declined by 29% between 1998-2004, but was accompanied by a 43% reduction in the PCI treatment of cardiogenic shock.

NY PCI Mortality: 1998-2004PCI for Cardiogenic Shock

1998-2004

Survival with Cardiogenic ShockBrighamandWomen’sHospital

Hochman J et al. The SHOCK Trial 1999

Immediate revascularization confers sustained survival benefit is similar whether PCI or CABG is used.

Risk Avoidance: Lessons from NYBrighamandWomen’sHospital

Michigan, with no public reporting, was compared to NY State for PCI risk factors and outcomes.

Adapted from: Moscucci et al. JACC 45(11). June 2005.

MI Shock: 2.56%

MA Shock: 2.28%

NY Shock: 0.38%

MI Shock: 2.56%

NY State in the SHOCK TrialBrighamandWomen’sHospital

Apolito RA et al. Am Heart J February 2008

• Investigators explored practice patterns of participating centers from NY State and all other U.S. enrolling centers in the SHOCK trial.

• NY State was only state mandating public release of risk adjusted outcomes.

• Provided a contemporaneous comparison with rigorous data collection and follow-up of high risk patient population in NY as compared with other regions.



After institution of public reporting, centers in NY demonstrated lower rates of emergent revascularization as compared to non-NY centers.

Time to CABG:

NY = 101.2 hrNon-NY = 10.1hr



Selective utilization leads to decreased mortality for PCI and CABG in Shock patients….However, overall mortality is increased in NY as compared to other states.



Comparing NY and MABrighamandWomen’sHospital

Analysis based on data excerpted from public cardiac reports and U.S. census data

Comparison of 2003 revascularization rates for cardiogenic shock demonstrate a 2-fold difference between the States.

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Risk Adjustment SpecificityBrighamandWomen’sHospital

Resnic FS and Welt FG Public Health Hazards of Risk Avoidance - JACC 2009

We reviewed over 5,000 consecutive PCI procedures at BWH to assess the adequacy of data collection systems and risk adjustment algorithms for predicting mortality post-PCI.

DefinitePCI Related

PossiblePCI Related

NOTProcedureRelated

MA Public Reporting: So What?





Decline of rate of revascularization in Cardiogenic Shock in Massachusetts


Source: Mass-DAC Data Review. November 2007

37%

43%

Between 2003 and 2005, the rates of revascularization in Massachusetts declined 37-43%


ClinicalOutcomes

ProcessMeasures

Appropriateness

Access toHealthcare

Impact on Access to CareBrighamandWomen’sHospital

Source: Werner RM, Asch DA and Polsky D. Circulation March 2005

Disparities in access to CABG increased in NY, relative to other states, after the release of report cards

ReducedAccess

ImprovedAccess

Operator Volume and PCI OutcomesBrighamandWomen’sHospital

Source: Moscucci et al. JACC August 2005

Exploration of Michigan data revealed a consistent trend toward improved risk adjusted outcomes with increasing operator volumes.

Operator Volume and PCI OutcomesBrighamandWomen’sHospital

Source: Moscucci et al. JACC August 2005

…. This trend was preserved within each expected risk quartile. Even in the lowest risk patients, low volume operators conferred twice the risk for death than high volume counterparts.


ClinicalOutcomes

ProcessMeasures

Appropriateness

Access toHealthcare

Incremental Patient Health Benefit

↑ Patient Benefit

↑ Survival

↓ Patient Benefit

↓ Survival

↑ Patient Benefit

↓ Survival

↓ Patient Benefit

↑ SurvivalPhysician Preference

Patient Benefit

Appropriateness and Case Selection Creep


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50yo STEMIin Shock

Focal CAD w/ Angina

Focal CAD w/o Angina

65yo withAnt. STEMI

75yo STEMIin Shock

75yo ST Δ’sw/ Sepsis


Minimal CAD w/o Ischemia


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50yo STEMIin Shock

Focal CAD w/ Angina

Focal CAD w/o Angina

65yo withAnt. STEMI

75yo STEMIin Shock

75yo ST Δ’sw/ Sepsis


Minimal CAD w/o Ischemia


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Public Reporting can promote a

Perverse Incentive

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Improving Risk AdjustmentBrighamandWomen’sHospital

Decline of prevalence of Cardiogenic Shock in PCI and CABG in MA



Between 2003 and 2005, the rates of revascularization in Massachusetts declined 37-43%.....

Intro Comp Use Criteria

Outcomes of CU AdmissionsBrighamandWomen’sHospital

SOS Admissions, first PCI Compassionate Use Only SOS No CU SOS Total p-value

N Percent N Percent N Percent

All Cases 96 100.0% 5492 100.0% 5588 100.0%

Successful Procedure 76 79.2% 5176 94.2% 5252 94.0% <0.001

Post-Procedure Cardiogenic Shock 6 6.3% 148 2.7% 154 2.8% 0.035

New Renal Failure 7 7.3% 68 1.2% 75 1.3% <0.001

Any Bleeding Complication 14 14.6% 417 7.6% 431 7.7% 0.011

Bleeding - other/unknown source 8 8.3% 159 2.9% 167 3.0% 0.002

Any Vascular Complication 2 2.1% 48 0.9% 50 0.9% 0.212

Blood Products 25 26.0% 643 11.7% 668 12.0% <0.001

In-Hospital Death 67 69.8% 245 4.5% 312 5.6% <0.001

Primary Cause of Death Cardiac 46 47.9% 185 75.5% 231 4.1% 0.000

Neurologic 15 15.6% 12 4.9% 27 0.5% <0.001

Death in Lab 13 13.5% 27 0.5% 40 0.7% 0.356

Source: Mass-DAC October 2009

Improvement in Mortality Prediction Model (Shock/STEMI)




Improvement in Mortality Prediction Model (Shock/STEMI)

ROC Area: No CU: 0.87w. CU: 0.90

P<0.01

Why? Reclassification of CasesBrighamandWomen’sHospital


BrighamandWomen’sHospital Reclassification of Cases with CU


Decline of rate of revascularization in Cardiogenic Shock in Massachusetts



Between 2003 and 2005, the rates of revascularization in Massachusetts declined 37-43%.....

Intro Comp Use Criteria

Additional Physician InputBrighamandWomen’sHospital





ConclusionsBrighamandWomen’sHospital

• Monitoring the quality of cardiac procedures is essential, given the cost and consequences of these services.

– Historical failure of physicians to adequately police the process

• MA has the most statistically rigorous methods to evaluate risk-adjusted mortality, and is viewed as a model by other states

• Rigorous review of high quality risk-adjusted mortality data is necessary, but not sufficient, to assess the quality of cardiac care delivered in Massachusetts.

• Beyond risk-adjusted mortality, quality must also account for appropriateness of care, access to care, additional health related outcomes of care, and evaluate key processes of care delivered

Comprehensive Cardiac QualityBrighamandWomen’sHospital

ClinicalOutcomes

ProcessMeasures

Appropriateness

Access toHealthcare

Monitoring the Quality of Invasive Cardiac Services: The Unintended Consequences of Public Reporting Frederic S. Resnic, MD MSc, FACC Brigham and Women’s.

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