Public Reporting and the Budding Interventional Cardiologist
State-mandated public reporting of PCI outcomes seems to have created both opportunities and challenges for the trainee seeking employment.
With fellowship interview season right around the corner, I have been spending a lot of time researching prospective training programs in interventional cardiology. After completing the interview cycles for internal medicine residency and cardiology fellowship, I’ve come to think of this process of searching for an ideal program like courtship—the more you get to know your partner at the outset, the fewer surprises and regrets you will have in the future.
But how are you to really know a program? There are several key variables that influence selection of interventional cardiology fellowship programs, including public reporting of PCI outcomes in certain states. Though these programs have faced criticism, I think publicly reported metrics represent a crucial variable that should be taken into consideration by trainees and early-career interventional cardiologists when choosing where they’d like to train and work.
What Is Public Reporting?
The New York Department of Health was the first to come out with a policy of hospitals reporting 30-day mortality outcomes following PCI in the 1990s. It was initiated as an effort to improve quality of care and to aid the public in selecting providers for cardiac interventions by increased transparency. Currently, Massachusetts, Texas, and Washington also have similar reporting systems.
Research has shown that public reporting has led to an unintended treatment-risk paradox, where certain hospitals are withholding lifesaving care from the sickest of patients who would also potentially gain the most—for example, revascularization in cardiogenic shock patients—and delivering care to the lowest-risk patients who potentially gain the least from it, such as revascularization for stable angina.
Because of this, trainees in states with public reporting may be faced with fewer opportunities to intervene on high-risk patients, such as those with acute MI and cardiogenic shock, resuscitated cardiac arrest, complex multivessel disease, or active cancer. This trend also tends to influence practicing interventional cardiologists, who may be forced into this paradox due to institutional and departmental pressures or the fear of public embarrassment from reporting.
As an attempt to mitigate this risk aversion, New York excluded patients with cardiogenic shock (systolic blood pressure < 80 mm Hg or low cardiac index < 2.0 L/min/m2 despite pharmacological or mechanical support) and cardiac arrest after an acute MI with anoxic encephalopathy from their public reports in 2008 and 2010, respectively. Instead, they began to report risk-adjusted mortality rates for institutions and providers.
Following these changes, reports showed an increase in PCI for cardiogenic shock patients. However, there is still tremendous criticism on the inadequacies of the risk-adjusted model used.
What Should Trainees Know?
Even though the public reports for mortality in New York are risk-adjusted for cardiogenic shock and cardiac arrest, they don't account for a variety of other variables that tend to influence 30-day mortality following a PCI, namely case mix. Certain hospitals may have a greater proportion of emergent cases (ie, STEMI) versus nonemergent/elective cases. Additionally, referral centers with cardiothoracic surgery backup that have ventricular assist devices available are where more complex interventions are routinely performed. Thus, some institutions may have higher adjusted mortality rates despite having similar or better PCI quality compared with other hospitals.
The current model also fails to differentiate between unpreventable deaths as well as deaths due to patient comorbidities and those related specifically to PCI.
Obviously, choosing a program to train or work at depends on multiple variables, including supportive mentors, opportunities for growth, supervised autonomy, and geographic and family preferences. However, having knowledge of public reporting policies of your training state and its influence of institutional metrics along with its unintended consequence may influence a young professional’s choice for further training or employment, as it doesn’t seem to be going away anytime soon.