Albany, NY - Concerned about going from notable to notorious when their names are published alongside their procedure-related mortality figures, New York PCI practitioners are less willing to treat patients with MI-related shock than their counterparts in states without such public reporting of operator-specific outcomes [1]. So conclude the authors of a retrospective analysis of US patients in the SHOCK registry appearing in the February 2008 issue of the American Heart Journal.

Although New York's Cardiac Surgery and Percutaneous Coronary Intervention Reporting System was designed largely to improve quality of care, the group observes, "There is evidence that for some patient cohorts it may do the opposite." One possibility from the data is that the reporting system makes revascularization more likely for the "healthier" patients with MI-related shock than for those who appear higher risk, according to the authors, led by Dr Renato A Apolito (New York University School of Medicine, NY).

This is a very real concern and would certainly be an unintended consequence of reporting and something that we need to track and understand.

"We posit that this is likely due to concern among interventionalists that the high mortality associated with cardiogenic shock would negatively impact their standing in New York's public report," they write. The conclusion is consistent with a number of other studies, some reported by heartwire [2,3], that have suggested New York's reporting system discourages operators from accepting all the cases they would otherwise take.

Dr Harlan M Krumholz (Yale University, New Haven, CT), who wasn't connected with the SHOCK analysis, agrees that it is, in fact, one of a growing number of studies questioning whether public reporting might be restricting healthcare access for some patients whom physicians believe will be a drag on their report-card standings.

"This is a very real concern and would certainly be an unintended consequence of reporting and something that we need to track and understand," Krumholz told heartwire. "It would be unfortunate if any physicians put concerns about their own ratings ahead patient interest, but it's natural for people to pause in taking patients who look like they are very high risk to the lab when they think there may be little chance of survival."

Apolito et al say their study is the first to explore the phenomenon specifically in patients with MI-related shock. What the analysis may indicate, Krumholz proposes, is a lack of trust that the reporting system's risk-adjusted outcomes figures truly account for the higher risk of patients in shock.

I think we're still in the early phases of public-reporting systems, and we need to work hard to prevent unintended consequences.

The analysis compared the registry's 325 patients treated in states without public reporting systems with the 220 New York patients, who were significantly less likely—after adjustment for propensity scores based on a long list of demographic, clinical, and laboratory risk factors—to undergo diagnostic angiography (odds ratio 0.46; 95% CI 0.31-0.68; p<0.001) or PCI (OR 0.51; 95% CI 0.33-0.77; p=0.002). There was no such significant difference for CABG. However, among those getting the surgery, 75.5% of non-New York patients but only 32.3% of New York patients (p<0.001) had it within three days of shock onset.

The adjusted risk of in-hospital death for New York patients vs non-New York patients was increased by 50% overall (OR 1.50; 95% CI 1.01-2.21; p=0.04) and more than doubled among those not getting either PCI or CABG (OR 2.12; 95% CI 1.20-3.75; p=0.01) but wasn't significantly different among those who were revascularized (OR 0.73; 95% CI 0.40-1.32; p=0.30).

"I think we're still in the early phases of public-reporting systems, and we need to work hard to prevent unintended consequences," Krumholz said. "This study isn't definitive, and we still don't really know whether public reporting has led to people who might have benefited from the procedures being turned away, but I think it speaks to the need for us to develop the means to track it and figure out how best to avoid it."