State Regulations Tied to Drop in Common Heart Procedure
TUESDAY, Oct. 9 -- If you suffer a serious heart attack, your medical treatment could depend on where you are when you have it.
If you're in a U.S. state with mandatory hospital public reporting, you may be less likely to get angioplasty to treat a blocked artery than if you were in a state without such data collection, a new study suggests.
Those at greatest risk for being sidelined from the procedure are those considered at the highest risk of dying or developing complications from the procedure, and thus the most likely to lower a hospital's performance grade.
Researchers found that Medicare patients who had heart attacks in the three states with mandatory hospital reporting had 18 percent lower odds of receiving an angioplasty or stent than did people in states without the reporting requirement.
Those who were considered extremely sick -- people arriving at the hospital with clear evidence of a massive heart attack -- had about a 27 percent lower chance of getting the treatment than did comparable people in other states. The study was published in the Oct. 10 issue of the Journal of the American Medical Association.
"This shouldn't be seen as an indictment of data transparency," said Dr. Karen Joynt, a lead study author, instructor at Harvard Medical School and associate cardiologist at Brigham and Women's Hospital in Boston.
"It's important to make performance data available to patients," Joynt said. "But we need not only a philosophy of transparency in the culture, but also the ability to capture the right data to improve conditions. Otherwise we may be creating incentives to deny care to the sickest patients."
The researchers found no evidence that public reporting was associated with a reduction in the number of deaths of patients with acute heart attacks. This, said Joynt, shows that "both overuse and underuse of angioplasty were evident because the mortality risks didn't drop" after mandatory public reporting was initiated.
Part of the challenge, Joynt explained, is choosing who shouldn't get a procedure based on the data. "People are starting to realize these decisions are not easy," she said.
"We have a hard time predicting how really sick patients are going to do," Joynt explained. "Say a patient is flown in from Maine and is told that the Brigham [hospital] is going to give them a chance. It's really hard to tell them we've sized up their situation and there's nothing we can do to help them."
Only three states -- New York, Massachusetts and Pennsylvania -- currently require patient outcome reporting after angioplasty or "stenting," called percutaneous coronary intervention. Other states have voluntary reporting programs.
Angioplasty is a nonsurgical procedure used to treat narrowed coronary heart arteries found in coronary heart disease. The cardiologist feeds a deflated balloon or other device on a catheter up through an artery until it reaches the blockage in the heart, when the balloon is opened, allowing blood to flow. Sometimes a stent is placed at the point of the blockage to expand the artery more permanently.
More than 500,000 percutaneous coronary interventions are performed in the United States each year, at a cost that exceeds $12 billion, according to research published in the Journal of the American Medical Association last year.
The researchers used data exclusively from Medicare patients, comparing 49,660 patients in mandatory reporting states with 48,142 patients in non-reporting states. All were admitted with the diagnosis of a heart attack, called acute myocardial infarction, to U.S. hospitals between 2002 and 2010.
The investigators compared the percutaneous intervention and mortality rates between the reporting states and eastern states without the reporting requirements: Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland and Delaware. The researchers also looked at how stenting rates changed before and after mandatory reporting was initiated in Massachusetts.
Dr. Mauro Moscucci, a professor of medicine and chief of the cardiovascular division at the University of Miami Miller School of Medicine, who wrote an accompanying journal editorial, said the study raises two issues.
"First, this study and a previous 2005 study that looked at Michigan show that public reporting can result in the denial of care," he said. "Secondly, as physicians, we are often asked and pressed to perform procedures that may result in no better outcomes."
The Michigan study, which looked at health program payments funded by the auto industry, did not involve Medicare specifically and was not technically public reporting.
Moscucci explained it can take a doctor far longer to explain to a family why a procedure is most likely not going to be effective than it would to simply go ahead and do the angioplasty.
"My concern is that we're doing more and more in patients who will not benefit," Moscucci said. "Physicians want access to new technology, they often stand to gain financially [by doing more procedures] in our fee-for-service system, they are prone to want to please patients, and they are afraid of adverse outcomes, such as a lawsuit, if they refuse to do the procedure."
Commenting on the study, another expert says that despite potential concerns about reduced access to care for the sickest patients, public reporting requirements are only likely to spread.
"The states now reporting won't go back," said Jane Bolin, an associate professor of health policy and management at Texas A&M Health Science Center School of Rural Public Health. "This particular study and others will push for more and more states to improve their outcomes through data. I don't see us pulling back from reporting outcomes publicly."
Learn more about angioplasty from the U.S. National Library of Medicine.
Posted: October 2012