Mandatory reporting may restrict high-risk care

A new study reinforces previous work showing that public reporting of angioplasty outcomes leads cardiologists to avoid high-risk patients

"Public reporting has the unintended effect of biasing physicians against giving care to those who are the highest risk," said Mauro Moscucci, MD, lead author of "Public Reporting and Case Selection for Percutaneous Coronary Interventions" published in the June 7 issue of Journal of the American College of Cardiology. This can lead to patients missing out on beneficial care, he said.

In addition, Dr. Moscucci found that physicians did not actually earn lower performance scores by having a larger number of high-risk patients.

"Our study suggests that the risk adjustment methodology is pretty robust," he said.

Dr. Moscucci and his colleagues at the University of Michigan Health System and the State University of New York-Stony Brook School of Medicine looked at registries of angioplasty results in Michigan, which has no public reporting system, and compared them with New York's registry results, where reporting is mandatory.

They found that the patients treated in Michigan had a significantly higher number of risk factors than those in New York. Also, Michigan's cardiologists did angioplasties for patients with cardiogenic shock, acute myocardial infarction and cardiac arrest more frequently than New York's cardiologists did.

As a result Michigan's cardiologists had more patients die than physicians in New York. However, after adjusting for patients' age, gender and other clinical risk factors as well as hospital procedure volume, the gap disappeared.

"We're not saying public reporting is bad," Dr. Moscucci said. "It can promote accountability, allow patients to shop around for care and push for quality improvement efforts. Physicians make sure outcomes are as good as they possibly can be, addressing the process of care. On the other hand, public reporting may have an unintended effect in denied care or referral bias [such as sending higher-risk patients out of state.] We need to do more analysis to move forward on the debate on this field."

AMA Trustee Cyril M. Hetsko, MD, said the AMA was deeply concerned about the unintended consequences that public reporting may have on patients and physicians, alike.

"A lot of the purchasers in the health care industry and insurance companies want to have public reporting," Dr. Hetsko said. "It's going to happen. Unfortunately the road is very uneven and full of potholes, and there are many problems with it."

Though Dr. Moscucci's study showed that risk-adjusted performance models could work, Dr. Hetsko said the accuracy of those models would always be questioned.

"If you end up with a poor correction for high-risk populations, you're going to badly affect inner-city practices and medical centers and schools and also rural areas," Dr. Hetsko said. "That concerns us at the AMA."