Performance of Hospitals When Assessing Disease-Based Mortality Compared With Procedural Mortality for Patients With
Ashwin S Nathan1,2,3, Qun Xiang4, Daniel Wojdyla4
1Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia.
Insights
Assessing percutaneous coronary intervention (PCI) quality using risk-adjusted mortality shows moderate correlation between disease-specific and procedural outcomes. Nearly half of high-performing PCI hospitals were reclassified using disease metrics, indicating potential risk aversion in high-risk acute myocardial infarction patients.
Area of Science:
- Cardiovascular Medicine
- Health Services Research
- Interventional Cardiology
Background:
- Percutaneous coronary intervention (PCI) quality is often evaluated using risk-adjusted mortality rates.
- This metric may lead to risk aversion, particularly for high-risk patients undergoing PCI.
- Understanding the correlation between disease-specific and procedural mortality is crucial for accurate quality assessment.
Purpose of the Study:
- To determine the correlation and reclassification between hospital-level disease-specific mortality and PCI procedural mortality in acute myocardial infarction (AMI) patients.
- To investigate potential risk aversion in PCI procedures for high-risk AMI subsets.
Main Methods:
- A multicenter, observational, cross-sectional analysis using data from the Chest Pain-MI Registry and CathPCI Registry (April 2011-December 2017).
- Calculated excess mortality ratios (EMR-D for disease-specific AMI mortality and EMR-P for PCI procedural mortality) for 625 linked hospitals.
- Analyzed correlation (Spearman rank coefficient) and reclassification across tertiles of performance, and used Bland-Altman plots to compare mortality metrics.
Main Results:
- A moderate correlation (ρ = 0.53) was found between disease-based (EMR-D) and procedural (EMR-P) excess mortality ratios.
- Nearly half of hospitals in the highest tertile for PCI performance were reclassified into a lower tertile based on disease-specific metrics.
- Procedural mortality was higher than disease-based mortality overall, but lower in patients with AMI complicated by cardiogenic shock or cardiac arrest, suggesting risk avoidance.
Conclusions:
- Hospital performance in PCI shows only a moderate correlation with disease-specific outcomes for acute myocardial infarction patients.
- Disease-specific metrics reclassify nearly half of high-performing PCI hospitals, highlighting discrepancies in quality assessment.
- Findings suggest potential risk avoidance in treating the highest-risk AMI patients (cardiogenic shock/cardiac arrest) when assessed by procedural vs. disease-based mortality.
Importance:
Quality of percutaneous coronary intervention (PCI) is commonly assessed by risk-adjusted mortality. However, this metric may result in procedural risk aversion, especially for high-risk patients.
Objective:
To determine correlation and reclassification between hospital-level disease-specific mortality and PCI procedural mortality among patients with acute myocardial infarction (AMI).
Design, Setting, And Participants:
This hospital-level observational cross-sectional multicenter analysis included hospitals participating in the Chest Pain-MI Registry, which enrolled consecutive adult patients admitted with a diagnosis of type I non-ST-segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI), and hospitals in the CathPCI Registry, which enrolled consecutive adult patients treated with PCI with an indication of NSTEMI or STEMI, between April 1, 2011, and December 31, 2017.
Exposures:
Inclusion into the National Cardiovascular Data Registry Chest Pain-MI and CathPCI registries.
Main Outcomes And Measures:
For each hospital in each registry, a disease-based excess mortality ratio (EMR-D) for AMI was calculated, which represents a risk-adjusted observed to expected rate of mortality for AMI as a disease using the Chest Pain-MI Registry, and a procedure-based excess mortality ratio (EMR-P) for PCI was calculated using the CathPCI Registry.
Results:
A subset of 625 sites participated in both registries, with a final count of 776 890 patients from the Chest Pain-MI Registry (509 576 men [65.6%]; 620 981 white [80.0%]; and median age, 64 years [interquartile range, 55-74 years]) and 853 386 patients from the CathPCI Registry (582 701 men [68.3%]; 691 236 white [81.0%]; and median age, 63 years [interquartile range, 54-73 years]). Among the 625 linked hospitals, the Spearman rank correlation coefficient between EMR-D and EMR-P produced a ρ of 0.53 (95% CI, 0.47-0.58), suggesting moderate correlation. Among the highest-performing tertile for disease-based risk-adjusted mortality, 90 of 208 sites (43.3%) were classified into a lower category for procedural risk-adjusted mortality. Among the lowest-performing tertile for disease-based risk-adjusted mortality, 92 of 208 sites (44.2%) were classified into a higher category for procedural risk-adjusted mortality. Bland-Altman plots for the overall linked cohort demonstrate a mean difference between EMR-P and EMR-D of 0.49% (95% CI, -1.61% to 2.58%; P < .001), with procedural mortality higher than disease-based mortality. However, among patients with AMI complicated by cardiogenic shock or cardiac arrest, the mean difference between EMR-P and EMR-D was -0.64% (95% CI, -4.41% to 3.12%; P < .001), with procedural mortality lower than disease-based mortality.
Conclusions And Relevance:
This study suggests that, for hospitals treating patients with AMI, there is only a moderate correlation between procedural outcomes and disease-based outcomes. Nearly half of hospitals in the highest tertile of performance for PCI performance were reclassified into a lower performance tertile when judged by disease-based metrics. Higher rates of mortality were observed when using disease-based metrics compared with procedural metrics when assessing patients with cardiogenic shock and/or cardiac arrest, signifying what appears to be potential risk avoidance among this highest-risk subset of patients.
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