Association of Public Reporting for Percutaneous Coronary Intervention With Utilization and Outcomes Among Medicare Beneficiaries With Acute Myocardial Infarction
Association of Public Reporting for Percutaneous Coronary Intervention With Utilization and Outcomes Among Medicare Beneficiaries With Acute Myocardial Infarction
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DOI：
10.1001/jama.2012.12922
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发表时间：
2012-10-10
影响因子：
120.7
通讯作者：
Jha, Ashish K.
中科院分区：
文献类型：
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作者：
Joynt, Karen E.;Blumenthal, Daniel M.;Jha, Ashish K.
背景 患者结果的公开报告是提高护理质量的重要工具，但一些观察者担心这种努力将导致临床医生避开高风险患者。 目的 确定经皮冠状动脉介入治疗 (PCI) 的公开报告是否与急性心肌梗死 (MI) 患者的 PCI 率降低或该人群的死亡率较高相关。 设计、设置和患者 回顾性观察性研究使用来自付费医疗保险患者的数据进行（来自报告州的 49 660 名患者和来自 48 个州的患者）。 2002 年至 2010 年间，有 142 名来自未报告州的患者因急性心梗入院。Logistic 回归用于比较报告州（纽约州、马萨诸塞州和宾夕法尼亚州）和地区性未报告州（缅因州、佛蒙特州、新罕布什尔州、康涅狄格州、罗德岛州、马里兰州和特拉华州）之间的 PCI 和死亡率。还检查了马萨诸塞州与未报告州相比 PCI 率随时间的变化。主要结果指标风险调整后的 PCI 和死亡率。结果 2010 年，与未报告州相比，公开报告州的急性心肌梗死患者接受 PCI 的可能性较低（未调整率分别为 37.7% 和 42.7%；风险调整比值比 [OR]，0.82 [95% CI， 0.71-0.93]；P=.003)。 6708 名 ST 段抬高 MI 患者（61.8% vs 68.0%；OR，0.73 [95% CI，0.59-0.89]；P=0.002）和 2194 名心源性休克或心脏骤停患者（41.5% vs 46.7%；OR，0.79 [95% CI， 0.64-0.98]；P=.03)。报告州与未报告州的急性心肌梗死患者的总体死亡率没有差异。在马萨诸塞州，急性心肌梗死的 PCI 几率与公开报告之前未报告的州的几率相当（40.6% vs 41.8%；OR，1.00 [95% CI，0.71-1.41]）。然而，实施公开报告后，马萨诸塞州接受 PCI 的几率与未报告的州相比有所下降（41.1% vs 45.6%；OR，0.81 [95% CI，0.47-1.38]；差异中的差异 P=.03）。 6081 名心源性休克或心脏骤停患者的差异最为明显（预报告：44.2% vs 36.6%；OR，1.40 [95% CI，0.85-2.32]；后报告：43.9% vs 44.8%；OR，0.92 [95% CI，0.38-2.22]；差异 P=.03结论 在患有急性 MI 的 Medicare 受益人中，与在 7 个未公开报告的区域对照州接受治疗的患者相比，在 3 个公开报告 PCI 结果的州接受治疗的患者的 PCI 使用率较低。然而，有和没有公开报告的州之间的急性心肌梗死总体死亡率没有差异。贾马。 2012;308(14):1460-1468 www.jama.com
Context Public reporting of patient outcomes is an important tool to improve quality of care, but some observers worry that such efforts will lead clinicians to avoid high-risk patients.Objective To determine whether public reporting for percutaneous coronary intervention (PCI) is associated with lower rates of PCI for patients with acute myocardial infarction (MI) or with higher mortality rates in this population.Design, Setting, and Patients Retrospective observational study conducted using data from fee-for-service Medicare patients (49 660 from reporting states and 48 142 from nonreporting states) admitted with acute MI to US acute care hospitals between 2002 and 2010. Logistic regression was used to compare PCI and mortality rates between reporting states (New York, Massachusetts, and Pennsylvania) and regional nonreporting states (Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland, and Delaware). Changes in PCI rates over time in Massachusetts compared with nonreporting states were also examined.Main Outcome Measures Risk-adjusted PCI and mortality rates.Results In 2010, patients with acute MI were less likely to receive PCI in public reporting states than in nonreporting states (unadjusted rates, 37.7% vs 42.7%, respectively; risk-adjusted odds ratio [OR], 0.82 [95% CI, 0.71-0.93]; P=.003). Differences were greatest among the 6708 patients with ST-segment elevation MI (61.8% vs 68.0%; OR, 0.73 [95% CI, 0.59-0.89]; P=.002) and the 2194 patients with cardiogenic shock or cardiac arrest (41.5% vs 46.7%; OR, 0.79 [95% CI, 0.64-0.98]; P=.03). There were no differences in overall mortality among patients with acute MI in reporting vs nonreporting states. In Massachusetts, odds of PCI for acute MI were comparable with odds in nonreporting states prior to public reporting (40.6% vs 41.8%; OR, 1.00 [95% CI, 0.71-1.41]). However, after implementation of public reporting, odds of undergoing PCI in Massachusetts decreased compared with nonreporting states (41.1% vs 45.6%; OR, 0.81 [95% CI, 0.47-1.38]; P=.03 for difference in differences). Differences were most pronounced for the 6081 patients with cardiogenic shock or cardiac arrest (prereporting: 44.2% vs 36.6%; OR, 1.40 [95% CI, 0.85-2.32]; postreporting: 43.9% vs 44.8%; OR, 0.92 [95% CI, 0.38-2.22]; P=.03 for difference in differences).Conclusions Among Medicare beneficiaries with acute MI, the use of PCI was lower for patients treated in 3 states with public reporting of PCI outcomes compared with patients treated in 7 regional control states without public reporting. However, there was no difference in overall acute MI mortality between states with and without public reporting. JAMA. 2012;308(14):1460-1468 www.jama.com