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Due to the complexity inherent in performing adequate risk adjustment for patients with out-of-hospital cardiac arrest, such cases should be tracked but not publicly reported or used for overall percutaneous coronary intervention (PCI) performance ranking, according to a scientific statement from the American Heart Association (AHA) published online July 15, 2013, ahead of print in Circulation.
The 2010 AHA Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care state that “appropriate treatment of ACS or STEMI, including PCI, should be initiated regardless of coma” and that “coma and the use of induced hypothermia are not contraindications or reasons to delay PCI.” Furthermore, they state that “PCI after [return of spontaneous circulation] in subjects with arrest of presumed cardiac etiology may be reasonable, even in the absence of a clearly defined STEMI.”
In a telephone interview with TCTMD, Mary Ann Peberdy, MD, of Virginia Commonwealth University (Richmond, VA), who chaired the new statement’s writing committee, said the document came partly as a response to concerns from hospitals around the country that have high publicly reported mortality rates as a result of providing this type of aggressive care of post-arrest patients, the vast majority of whom are comatose on arrival.
In one of the most publicized instances, the Boston Globe published an article in 2011 criticizing the care at Beth Israel Deaconess Medical Center after the addition of a cardiac resuscitation center there led to the hospital having the highest mortality rate in the state of Massachusetts. The AHA scientific statement contends that the addition of just 15 cardiac arrest STEMI cases, which is common for a high-volume cardiac resuscitation center, can double the reportable STEMI PCI mortality for that hospital compared with noncardiac resuscitation center hospitals due to the approximate 50% mortality rate of these high-risk patients.
Dr. Peberdy said the situation puts providers in “an ethical box” because getting appropriate post-arrest patients “immediate access to the cath lab involves treating many who will ultimately succumb to neurological or multiorgan failure rather than a cardiovascular death, yet their deaths are reported simultaneously with all other STEMI patients.” According to the AHA statement, this federal- and state-mandated public reporting influences physician decision making about whether to take high-risk patients for lifesaving procedures, and often results in needing to decide between “protecting their publicly reported reputation or jeopardizing future reimbursement and providing what the evidence has demonstrated to be the best clinical care for their patients.”
For this reason, the committee suggests that out-of-hospital cardiac arrest cases “be included in quality reporting if appropriate risk adjustment could be made.” Because that is unlikely, however, the statement recommends that such cases simply be tracked so as to allow accountability for hospitals’ management without penalizing high-volume cardiac resuscitation centers.
New York State Registry Takes Lead
The AHA statement discusses how several prominent national and statewide PCI reporting systems have attempted to address risk adjustment of cardiac arrest and how they include it as a covariate in reporting models.
Although a disparate and complex network of regulatory bodies report these data, the scientific statement focuses on the private, nonprofit National Quality Forum, the National Cardiovascular Data Registry (NCDR), the New York State Registry, and the Massachusetts Data Analysis Center (MASS-DAC). Of these, the one the committee felt has taken the most significant measures to adjust for the exceptionally high and often noncardiovascular mortality rate in cardiac arrest patients is the New York State Registry.
“I applaud them for truly being the first to acknowledge this issue, but unfortunately the criteria that they developed are next to impossible to meet so it’s probably not going to make that much of a difference in the reporting,” Dr. Peberdy said. “But they are going back to the table and trying again.”
If a large registry such as New York State did decide to exclude cardiac arrest from reporting, Dr. Peberdy said, the hope is that others would follow suit. But she added that there are those who believe strongly that adequate risk adjustment is feasible. Still, there is precedent for excluding conditions from reporting as evidenced by the exclusion in recent years of cardiogenic shock from total PCI mortality, the committee notes. Dr. Peberdy said those decisions, however, are made individually by the various registries and agencies since no single governing body oversees them.
Overall, Dr. Peberdy said the committee does not dispute the potential benefits of public reporting of PCI outcomes.
“We tried to come at our recommendation from the perspective that [public reporting] is good. It helps us learn and practice within tighter standards,” Dr. Peberdy said. “The purpose is really to try to make all of us better as clinicians while keeping the public informed about the care that they are receiving at different institutions.
“We are not advocating that cardiac arrest patients not be included in publicly reported registries,” she concluded, adding that much remains to be learned from post-arrest patients in the setting of return of spontaneous circulation that could ultimately be used to develop true performance measures.