Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA.
JAMA. 2012 Oct 10;308(14):1460-8. doi: 10.1001/jama.2012.12922.
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.
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.
Risk-adjusted PCI and mortality rates.
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).
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.
患者结局的公开报告是提高医疗质量的重要工具，但一些观察家担心，这些努力将导致临床医生回避高危患者。
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升高有关。
设计、设置和患者：使用 2002 年至 2010 年期间美国急性护理医院收治的急性 MI 入住的医疗保险按服务收费患者（报告州 49660 例，非报告州 48142 例）的数据进行回顾性观察性研究。使用逻辑回归比较报告州（纽约州、马萨诸塞州和宾夕法尼亚州）和区域非报告州（缅因州、佛蒙特州、新罕布什尔州、康涅狄格州、罗得岛州、马里兰州和特拉华州）的 PCI 和死亡率。还检查了马萨诸塞州与非报告州相比 PCI 率随时间的变化。
风险调整后的 PCI 和死亡率。
2010 年，与非报告州相比，急性 MI 患者接受 PCI 的可能性较小（未经调整的比率分别为 37.7%和 42.7%；风险调整后比值比 [OR]，0.82 [95%CI，0.71-0.93]；P =.003）。在 ST 段抬高 MI（61.8%与 68.0%；OR，0.73 [95%CI，0.59-0.89]；P =.002）和心源性休克或心搏骤停（41.5%与 46.7%；OR，0.79 [95%CI，0.64-0.98]；P =.03）的 6708 例患者和 2194 例患者中，差异最大。在报告州和非报告州的急性 MI 患者中，总死亡率无差异。在马萨诸塞州，急性 MI 的 PCI 几率与报告前非报告州的 PCI 几率相当（40.6%与 41.8%；OR，1.00 [95%CI，0.71-1.41]）。然而，在公开报告实施后，马萨诸塞州接受 PCI 的几率与非报告州相比下降（41.1%与 45.6%；OR，0.81 [95%CI，0.47-1.38]；P =.03 为差异差异）。对于心源性休克或心搏骤停的 6081 例患者，差异最为明显（报告前：44.2%与 36.6%；OR，1.40 [95%CI，0.85-2.32]；报告后：43.9%与 44.8%；OR，0.92 [95%CI，0.38-2.22]；P =.03 为差异差异）。
在急性 MI 的医疗保险受益人群中，与无公开报告 PCI 结果的 7 个区域对照州相比，3 个州的 PCI 使用率较低。然而，有报告和无报告州之间的急性 MI 总死亡率没有差异。
