Responses are included from 149 interventional cardiologists in Massachusetts and New York to 5 survey questions about public reporting of percutaneous coronary intervention (PCI) outcomes, systems-level support for performing PCIs in high-risk patients, individual clinicians’ avoidance of high-risk PCIs, and interventional cardiologists’ impressions of the prevalence of purposeful upcoding of comorbidities by colleagues.
eAppendix 1. Public Reporting Survey.
eAppendix 2. Detailed Overview of Study Methods.
eAppendix 3. Healthcare Common Procedural Coding System (HCPCS) Codes for Percutaneous Coronary Intervention (PCI).
eAppendix 4. Methods Used to Calculate Each Physician’s Years Practicing Interventional Cardiology.
eTable 1. Hospital Characteristics of Respondents and Non-Respondents.
eTable 2. Comparison of Unweighted Survey Responses with Responses Weighted for Predicted Likelihood of Survey Response.
eTable 3. Predictors of Responses to Questions about Risk Aversion in Univariable and Multivariable Analysis.
eFigure 1. Respondents’ Views on Supervisory Support for Performing Percutaneous Coronary Interventions In Patients Who Die Later in Their Hospitalization.
eFigure 2. Degree to Which Respondents Worry About How Procedural Complications Will Impact Their Own or Their Facility’s Reputation.
eFigure 3. Respondents’ Knowledge and Trust of Risk-Adjustment Methods used by Public Reporting Systems.
eFigure 4. Respondents’ Beliefs About Whether and How PCI Public Reporting Facilitates Hospital Quality Improvement Efforts and Patient Informed Decision Making.
eFigure 5. Degree to Which Respondents Worry About A How Procedural Complications Will Impact Their Own or Their Facility’s Reputation.
eFigure 6. Respondents’ Views on Public Reporting of PCI Outcomes in Patients with Cardiogenic Shock, Cardiac Arrest, and Cardiac Arrest Complicated by Coma.
eFigure 7. Influence of Public Reporting of PCI Outcomes on Avoidance of High-Risk Patients With Different Perceived Likelihoods of Benefiting from PCI.
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Blumenthal DM, Valsdottir LR, Zhao Y, et al. A Survey of Interventional Cardiologists’ Attitudes and Beliefs About Public Reporting of Percutaneous Coronary Intervention. JAMA Cardiol. 2018;3(7):629–634. doi:10.1001/jamacardio.2018.1095
How does public reporting of percutaneous coronary intervention outcomes influence clinical decision making of interventional cardiologists in New York and Massachusetts?
In this online survey of interventional cardiologists in Massachusetts and New York, 65% of participants reported avoiding percutaneous coronary intervention on at least 2 occasions, and 59% reported sometimes or often being pressured by colleagues to avoid PCIs because of concerns about public reporting.
Despite reforms intended to limit reporting of outcomes for critically ill and high-risk patients undergoing percutaneous coronary intervention, current programs continue to promote risk-averse clinical practice.
Public reporting of procedural outcomes has been associated with lower rates of percutaneous coronary intervention (PCI) and worse outcomes after myocardial infarction. Contemporary data are limited on the influence of public reporting on interventional cardiologists’ clinical decision making.
To survey a contemporary cohort of interventional cardiologists in Massachusetts and New York about how public reporting of PCI outcomes influences clinical decision making.
Design, Setting, and Participants
An online survey was developed with public reporting experts and administered electronically to eligible physicians in Massachusetts and New York who were identified by Doximity (an online physician networking site) and 2014 Medicare fee-for-service claims for PCI procedures. The personal and hospital characteristics of participants were ascertained via a comprehensive database from Doximity and the American Hospital Association annual surveys of US hospitals (2012 and 2013) and linked to survey responses. Associations between survey responses and characteristics of participants were evaluated in univariable and multivariable analyses.
Main Outcomes and Measures
Reported rate of avoidance of performing PCIs in high-risk patients and of perception of pressure from colleagues to avoid performing PCIs.
Of the 456 physicians approached, 149 (32.7%) responded, including 67 of 129 (51.9%) in Massachusetts and 82 of 327 (25.1%) in New York. The mean (SD) age was 49 (9.2) years; 141 of 149 participants (94.6%) were men. Most participants reported practicing at medium to large, nonprofit hospitals with high-volume cardiac catheterization laboratories and cardiothoracic surgery capabilities. In 2014, participants had higher annual PCI volumes among Medicare patients than nonparticipants did (median, 31; interquartile range [IQR], 13-47 vs median, 17; IQR, 0-41; P < .001). Among participants, 65% reported avoiding PCIs on at least 2 occasions becase of concern that a bad outcome would negatively impact their publicly reported outcomes; 59% reported sometimes or often being pressured by colleagues to avoid performing PCIs because of a concern about the patient’s risk of death. After multivariable adjustment, more years of experience practicing interventional cardiology was associated with lower odds of PCI avoidance. The state of practice was not associated with survey responses.
Conclusions and Relevance
Current PCI public reporting programs can foster risk-averse clinical practice patterns, which do not vary significantly between interventional cardiologists in New York and Massachusetts. Coordinated efforts by policy makers, health systems leadership, and the interventional cardiology community are needed to mitigate these unintended consequences.
Several states, including Massachusetts and New York, mandate public reporting of short-term mortality rates after percutaneous coronary intervention (PCI). Public reporting has been associated with lower mortality after PCIs1 but may also promote PCI avoidance among physicians treating ST-elevation myocardial infarction, cardiogenic shock, and cardiac arrest.2-8
Two prior surveys of interventional cardiologists in New York found evidence of avoidance of PCI and mistrust of public reporting systems.9-11 These studies yielded limited information about how and why public reporting promotes risk aversion and whether it facilitates quality improvement and informed decision making. To build on this work, we surveyed interventional cardiologists in Massachusetts and New York about their knowledge, attitudes, and beliefs about public reporting of PCIs.
A survey was administered to a comprehensive cohort of interventional cardiologists in Massachusetts and New York between November 2016 and February 2017 using Research Electronic Data Capture, a secure, web-based research database.12 The personal and facility characteristics of all physicians identified as eligible to receive an invitation for the survey were obtained from Doximity, an online networking site for physicians; 2014 Medicare fee-for-service claims data; and the 2012 and 2013 American Hospital Association annual surveys of US hospitals. Physician-level data from Doximity have been previously validated and shown to be accurate.13,14 The total number of PCIs performed by each physician was extracted from the Medicare claims data set via International Classification of Diseases, Ninth Revision codes 00.66, 36.00, 36.06, 36.07, and 36.09, and Current Procedural Terminology codes 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, and 92944.
This study was approved by the institutional review board at Beth Israel Deaconess Medical Center. Survey completion was regarded as participants’ informed consent. Invitees were sent a $20 Amazon gift card via Research Electronic Data Capture, irrespective of survey completion, to incentivize participation.
Associations between survey responses and physician and facility characteristics were evaluated using univariable analysis and multivariable logistic regression in SAS, version 9.4 (SAS Institute). Personal and facility characteristics were also compared between participants and nonparticipants. A sensitivity analysis was performed to test for nonresponse bias. eAppendices 1 through 4 and eReferences in the Supplement contain the survey instrument and additional explanations of the methods. Any P value of .05 or less was regarded as significant.
The study survey was sent to 456 interventional cardiologists, of whom 149 participated. The response rate was 32.7% overall, with 67 of 129 physicians participating in Massachusetts (51.9%) and 82 of 327 (25.1%) participating in New York. The mean (SD) age was 49 (9.2) years; 141 of 149 (94.6%) were men (Table 1). Participants had practiced interventional cardiology for a mean (SD) of 18.2 (9.7) years. Most respondents practiced at medium to large hospitals with high PCI volumes and cardiothoracic surgery capabilities (eTable 1 in the Supplement).
The median (interquartile range [IQR]) number of PCIs among Medicare patients in 2014 was higher among participants (31 [13-47]) than nonparticipants (17 [0-41]; P < .001) (Table 1). No other significant differences were observed between the groups. Additional self-reported characteristics of participants and their facilities are in Table 2 and eTable 2 in the Supplement.
Of the 149 participants, 97 (59.1%) reported sometimes or often being pressured by colleagues to avoid an indicated PCI because of concern that the patient was at high risk of death (Figure); 89 of 149 (65.1%) reported avoiding PCIs at least twice because of concerns of a negative publicly reported outcome, and 141 of 149 (94.7%) believed that other interventionalists in their state sometimes or often avoid PCIs because of these concerns (Figure and eTable 3 in the Supplement).
Among the 149 participants, 77 (51.7%) worried some or a lot that their superiors would not support them for performing an indicated PCI in a critically ill patient who later died of a PCI-associated complication (eFigure 1 in the Supplement); 110 (73.8%) reported sometimes or often delaying a coronary angiography or PCI procedure in a patient in cardiac arrest because of concerns about the patient’s high risk of death (eFigure 2 in the Supplement). Four in 5 participants (121 of 149 [81.2%]) reported knowing some or a lot about public reporting systems’ risk adjustment methods. However, 110 of 149 (73.8%) had little or no trust in these methods (eFigure 3 in the Supplement). Among participants, 118 of 149 (79.2%) believed that public reporting of PCI outcomes did very little or nothing to help patients make more informed decisions about whether to undergo an elective PCI, and 88 of 149 (59.1%) thought that public reporting of PCI outcomes did very little or nothing to help patients decide which health care facility to go to for an elective coronary angiogram and/or PCI (eFigure 4 in the Supplement). In the sensitivity analysis, weighting responses for predicted probability of survey completion did not meaningfully change the distribution of responses regarding risk aversion or knowledge and trust of risk adjustment (eTable 2 in the Supplement). Additional findings are presented in eFigures 5-7 in the Supplement.
In multivariable regression, more experience practicing interventional cardiology was associated with lower odds of reporting pressure to avoid an indicated PCI (odds ratio [OR] per 1 year of experience: 0.94; 95% CI; 0.90-0.98; P = .002); lower odds of believing that other cardiologists avoid high-risk PCIs because of public reporting (OR, 0.90; 95% CI, 0.83-0.98; P = .02); higher odds of trusting risk adjustment methods (OR, 1.05; 95% CI, 1.01-1.09; P = .01); and insignificantly lower odds of reporting worry about being supported by supervisors for performing an indicated PCI in a critically ill patient (OR, 0.96; 95% CI, 0.93-1.00; P = .05) (eTable 3 in the Supplement).
Interventional cardiologists in Massachusetts had insignificantly lower odds than New York interventionalists of reporting avoiding high-risk PCIs at least twice (OR, 0.52; 95% CI, 0.26-1.04; P = .07) and were more likely to report trusting risk adjustment a lot or some (OR, 2.17; 95% CI, 0.97-4.76; P = .06) (eTable 3 in the Supplement).
These results suggest that risk-averse attitudes and practice patterns remain prevalent among interventional cardiologists in Massachusetts and New York; that some interventionalists are skeptical that public reporting improves care quality and informed decision making; and that some do not trust risk adjustment methods used by public reporting systems. This is the third survey examining how public reporting of PCI outcomes influences the practice of interventional cardiology. In 2003, Narins et al9 found evidence of pervasive risk-averse use of PCIs by New York interventionalists because of concerns about public reporting, particularly when treating critically ill patients; mistrust of risk adjustment methods; and upcoding of comorbidities (ie, coding comorbidities in ways that make the patient appear more complex or ill). More recently, Fernandez et al10 demonstrated that excluding patients with anoxic brain injury and cardiogenic shock from public reports increased interventionalists’ self-reported willingness to perform PCIs in these subgroups but did not eliminate avoidance of indicated PCIs. We also found that public reporting engenders aversion toward high-risk PCIs and distrust of risk adjustment methods among interventional cardiologists in both New York and Massachusetts.
To our knowledge, this study is the first to survey interventional cardiologists in Massachusetts about public reporting, and demonstrates that their concerns are consistent with those of interventionalists in New York. Furthermore, to our knowledge, this is the first attempt to quantify how many interventionalists avoid indicated PCI because of concerns about public reporting, and we found that nearly two-thirds of participants had done so at least twice. This suggests that PCI avoidance is not concentrated among a few risk-averse interventionalists. While we did not quantify rates of PCI avoidance among clinicians who acknowledged avoiding PCIs, any avoidance of an indicated procedure is concerning. Modifying public reporting systems to include all patients experiencing acute myocardial infarction, as opposed to patients undergoing PCIs alone, is a promising approach for further reducing risk-averse use of PCIs. Interventions designed to support and educate less-experienced clinicians may also help mitigate risk aversion.15
This study’s limitations include a 32.7% response rate, which could limit external generalizability. However, comparisons of participants and nonparticipants and a sensitivity analysis suggest that responses may be broadly representative. Nonetheless, our findings should be considered exploratory and hypothesis generating. Additionally, we did not evaluate cardiologists’ knowledge about why public reporting exists or how risk adjustment methods work in practice.
In summary, this study suggests that avoidance of PCIs because of concerns about public reporting remains pervasive in both Massachusetts and New York, that risk-averse practice patterns appear similar in Massachusetts and New York, and that less experienced interventionalists may be particularly prone to risk-averse use of PCIs. Coordinated efforts by policy makers, health systems leadership, and the interventional cardiology community are needed to ensure that public reporting of outcomes effectively improves accountability, care quality, and informed patient decision making.
Corresponding Author: Daniel M. Blumenthal, MD, MBA, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, 375 Longwood Ave, 4th Floor, Boston, MA 02115 (email@example.com).
Accepted for Publication: March 19, 2018.
Published Online: May 9, 2018. doi:10.1001/jamacardio.2018.1095
Author Contributions: Dr Blumenthal had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Blumenthal, Kirtane, Wasfy, Rosenfield, Yeh.
Acquisition, analysis, or interpretation of data: Blumenthal, Valsdottir, Zhao, Shen, Kirtane, Pinto, Resnic, Joynt Maddox, Mehran, Rosenfield.
Drafting of the manuscript: Blumenthal, Shen, Pinto, Wasfy.
Critical revision of the manuscript for important intellectual content: Blumenthal, Valsdottir, Zhao, Shen, Kirtane, Resnic, Joynt Maddox, Wasfy, Mehran, Rosenfield, Yeh.
Statistical analysis: Blumenthal, Zhao, Shen, Wasfy.
Obtained funding: Blumenthal, Yeh.
Administrative, technical, or material support: Blumenthal, Valsdottir, Wasfy.
Study supervision: Blumenthal, Kirtane, Resnic, Mehran, Rosenfield, Yeh.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Blumenthal reports receiving research support from the John S. LaDue Memorial Fellowship at Harvard Medical School and consulting fees and/or funding for unrelated work from Devoted Health, Novartis Pharmaceuticals, HLM Venture Partners, and Precision Health Economics. Dr Kirtane reports institutional grants to Columbia University and/or Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CathWorks, Siemens, Philips, and ReCor Medical. Dr Joynt Maddox reports support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (grant 5K23HL109177-03). Dr Wasfy reports a career development award from the National Institutes of Health and Harvard Catalyst (grant KL2 TR001100). Dr Yeh reports receiving research funding for investigator-initiated research from Abiomed for the conduct of this study. Dr Mehran reports institutional grants to Icahn School of Medicine at Mount Sinai from AstraZeneca, Bayer, Beth Israel Deaconess, Bristol-Myers Squibb, CSL Behring, Eli Lilly/Daiichi Sankyo, Medtronic, Novartis Pharmaceuticals, and OrbusNeich; consultant fees from Abbott Laboratories, CardioKinetix, Spectranetics, Boston Scientific, Cardiovascular Systems Inc, and Medscape; participation in advisory boards or executive committees of Bristol-Myers Squibb, Janssen Pharmaceuticals, and Osprey Medical; participation on the data and safety monitoring board of Watermark Research Partners; and equity stakes in Claret Medical and Elixir Medical. Dr Pinto reports personal fees from Medtronic, Boston Scientific, and Abiomed Inc. Dr Wasfy reports grants from the National Institutes of Health outside the submitted work. Dr Rosenfield reports research or fellowship support from Atrium-Getinge, Inari Medical, National Institutes of Health, and Lutonix-BARD; board membership on VIVA Physicians and National PERT Consortium; consultant or scientific advisory board positions with Abbott Vascular, Cardinal Health, Cook, Thrombolex, Surmodics, Volcano/Philips, and Amegen; consultant or scientific advisory board positions with stock or equity with Capture Vascular, Contego, Cruzar Systems, Endospan, Eximo, MD Insider, Micell, Shockwave, Silk Road Medical, Valcare, and Thrombolex; and personal equity in PQ Bypass, Primacea, Capture Vascular, VORTEX, MD Insider, Micell, Shockwave, Cruzar Systems, Endospan, Eximo, Valcare, and Contego. No other disclosures were reported.
Funding/Support: This study was supported by an unrestricted research grant from Abiomed, Inc, to the Smith Center for Outcomes Research in Cardiology at the Beth Israel Deaconess Medical Center.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; or collection, management, analysis, and interpretation of the data. Although representatives of the funder provided feedback on the manuscript prior to submission, the authors maintained complete and independent control over manuscript preparation and revision and the decision to submit the manuscript for publication.
Disclaimer: Dr Kirtane is Associate Editor of JAMA Cardiology, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.
Meeting Presentation: Preliminary findings from this study were presented at the American Heart Association Annual Scientific Sessions; November 13, 2017; Anaheim, California.
Additional Contributions: We thank Eric Campbell, PhD, Harvard Medical School, for his assistance with designing the survey instrument used in this study, and Douglas Drachman, MD, Massachusetts General Hospital and Harvard Medical School, IK Jang, MD, PhD, Massachusetts General Hospital and Harvard Medical School, Joseph Garasic, MD, Massachusetts General Hospital and Harvard Medical School, Stephen Waldo, MD, University of Colorado School of Medicine, and Kalon Ho, MD, MSc, Beth Israel Deaconess Medical Center and Harvard Medical School, for their assistance with reviewing and revising the survey instrument. We additionally thank the Society for Cardiovascular Angiography and Interventions and the Cardiovascular Research Foundation for their assistance with physician outreach. These individuals and organizations were not compensated for these contributions.