Impact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock

doi:10.1016/j.ahj.2007.10.013

American Heart Journal

Volume 155, Issue 2, February 2008, Pages 267-273

https://doi.org/10.1016/j.ahj.2007.10.013 Get rights and content

Background

Studies suggest that the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System, which makes public the operator-specific mortality for patients undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI), may deter operators from providing revascularization to high-risk cardiac patients in New York compared to other states.

Methods

We performed a retrospective analysis of 545 US patients with acute myocardial infarction and cardiogenic shock due to predominant left ventricular failure enrolled in the SHOCK Registry. Adjusting for case mix using a propensity score method, we compared the use of coronary angiography, PCI, CABG, and outcomes between 220 patients in New York and 325 in other states.

Results

New York patients were older with similar or less severe baseline characteristics. After propensity score adjustment, New York patients were less likely than non–New York patients to undergo coronary angiography (odds ratio 0.46, 95% CI 0.31-0.68, P < .001) and PCI (odds ratio 0.51, 95% CI 0.33-0.77, P = .002). Coronary artery bypass graft rates were similarly low (14.1% vs 15.1%, P = not significant), but New York patients waited significantly longer after shock onset for surgery (101.2 vs 10.3 hours, P < .001) with only 32.3% of New York patients vs 75.5% of non–New York patients (P < .001) taken for CABG within 3 days of shock onset.

Conclusions

In our propensity-adjusted retrospective analysis, New York patients with acute myocardial infarction and cardiogenic shock were less likely to undergo coronary angiography and PCI and waited significantly longer to receive CABG than their non–New York counterparts. These findings suggest that state-required reporting to the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System may result in the reluctance to revascularize the highest-risk cardiac patients.

Section snippets

Methods

The SHOCK Registry contains data from 1189 subjects from 36 multinational centers who were enrolled from April 1993 through August 1997. The Registry remains the largest prospective database dedicated to patients with suspected CS complicating AMI.¹² Whereas CS in the SHOCK Trial was strictly defined, the diagnosis of CS in the SHOCK Registry was made purely on clinical grounds. Patients were enrolled in the registry if they failed to meet trial inclusion criteria, met exclusion criteria, or

Patient characteristics

New York patients were significantly older (69.5 ± 12.5 vs 67.4 ± 11.5, P = .04), with a higher proportion of ≥75 years of age, compared to non–New York patients (36.4% vs 27.4%, P = .03) (Table I). New York patients less often had a history of elevated lipids (25.2% vs 47.2%, P < .001), smoking (42.4% vs 59.1%, P < .001), and renal insufficiency (6.6% vs 15.1%, P = .003) than non–New York patients. Non–New York patients had a higher rate of mechanical ventilation (83.7% vs 75.0%, P = .02) and

Discussion

The NYSCSPCIRS has stimulated substantial controversy since its implementation. Because it is available to both public and insurers, having an above-average risk-adjusted mortality may result in penalties, reduced reimbursements,⁵ or damage to one's reputation.⁷ In addition, a risk-adjusted mortality above the confidence interval of the statewide mean results in audits by the NYSDOH, possibly leading to penalties and probation.² Given these potential repercussions, it is plausible that New York

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Citation Excerpt :
Although the evidence for risk aversion among cardiac surgeons is debated, changes in referral patterns and time to intervention for high-risk patients have been documented in response to mandatory public outcomes reporting.5,7,8,17 Additionally, analysis of interventional cardiology data from states where public reporting is mandatory have demonstratively shown lower rates of intervention in patients who present in cardiogenic shock after acute myocardial infarction.18-21 Some have proposed that a potential solution to the problem of risk aversion is accurate risk adjustment for publicly reported outcomes.9
Outcomes in cardiac surgery are benchmarked against national Society of Thoracic Surgeons (STS) data and include patients undergoing elective, urgent, emergent, and salvage operations. This practice relies on accurate risk adjustment to avoid risk-averse behavior. We hypothesize that the STS risk calculator does not adequately characterize the risk of salvage operations because of their heterogeneity and infrequent occurrence.
Data on all cardiac surgery patients with an STS predicted risk score (2002-2017) were extracted from a regional database of 19 cardiac surgery centers. Patients were stratified according to operative status for univariate analysis. Observed-to-expected (O:E) ratios for mortality and composite morbidity/mortality were calculated and compared among elective, urgent, emergent, and salvage patients.
A total of 76,498 patients met inclusion criteria. The O:E mortality ratios for elective, urgent, and emergent cases were 0.96, 0.98, and 0.93, respectively (all P values > .05). However, mortality rate was significantly higher than expected for salvage patients (O:E ratio, 1.41; P = .04). Composite morbidity/mortality rate was lower than expected in elective (O:E ratio, 0.81; P = .0001) and urgent (O:E ratio, 0.93; P = .0001) cases but higher for emergent (O:E ratio, 1.13; P = .0006) and salvage (O:E ratio, 1.24; P = .01). O:E ratios for salvage mortality were highly variable among each of the 19 centers.
The current STS risk models do not adequately predict outcomes for salvage cardiac surgery patients. On the basis of these results, we recommend more detailed reporting of salvage outcomes to avoid risk aversion in these potentially life-saving operations.

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: This study was supported partially by grants RO1-HL50020 (Hochman) and RO1-HL49970 (Sleeper) from the National Heart, Lung, and Blood Institute, Bethesda, MD.

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Clinical InvestigationInterventional CardiologyImpact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock

Background

Methods

Results

Conclusions

Section snippets

Methods

Patient characteristics

Discussion

Ann Thorac Surg

Am Heart J

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

How a New York cardiac surgery program uses outcomes data

Ann Thorac Surg

Benefits and hazards of reporting medical outcomes publicly

N Engl J Med

Assessment of coronary artery bypass graft surgery performance in New York. Is there a bias against taking high-risk patients

Med Care

Quality of care information makes a difference: an analysis of market share and price changes after publication of the New York State Cardiac Surgery Mortality Reports

Med Care

Clinical Investigation
Interventional Cardiology
Impact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock