Samadashvili, Zaza

Background: Hospitals’ risk-standardized mortality rates and outlier status (significantly higher/lower rates) are reported by the Centers for Medicare and Medicaid Services (CMS) for acute myocardial infarction (AMI) patients using Medicare claims data. New York now has AMI claims data with blood pressure and heart rate added. Objective: The objective of this study was to see whether the appended database yields different hospital assessments than standard claims data. Methods: New York State clinically appended claims data for AMI were used to create 2 different risk models based on CMS methods: 1 with and 1 without the added clinical data. Model discrimination was compared, and differences between the models in hospital outlier status and tertile status were examined. Results: Mean arterial pressure and heart rate were both significant predictors of mortality in the clinically appended model. The C statistic for the model with the clinical variables added was significantly higher (0.803 vs. 0.773, P<0.001). The model without clinical variables identified 10 low outliers and all of them were percutaneous coronary intervention hospitals. When clinical variables were included in the model, only 6 of those 10 hospitals were low outliers, but there were 2 new low outliers. The model without clinical variables had only 3 high outliers, and the model with clinical variables included identified 2 new high outliers. Conclusion: Appending even a small number of clinical data elements to administrative data resulted in a difference in the assessment of hospital mortality outliers for AMI. The strategy of adding limited but important clinical data elements to administrative datasets should be considered when evaluating hospital quality for procedures and other medical conditions.

Background— Appropriate use criteria for diagnostic catheterization (DC) were recently published. These criteria are yet to be examined for a large population of patients undergoing DC. Methods and Results— New York State’s Cardiac Diagnostic Catheterization Database was used to identify patients undergoing DC for coronary artery disease between 2010 and 2011 for suspected coronary artery disease. Patients were rated by the appropriate use criteria as appropriate, uncertain, and inappropriate for DC. The relationships between various patient characteristics and the appropriateness ratings were examined, along with the relationships between hospital-level inappropriateness, for DC and 2 other hospital-level variables (hospital DC volume and percutaneous coronary intervention inappropriateness). Of the 8986 patients who could be rated for appropriateness, 35.3% were rated as appropriate, 39.8% as uncertain, and 24.9% as inappropriate. Of the 2240 patients rated as inappropriate, 56.7% were asymptomatic/had no previous stress test/had low or intermediate global coronary artery disease risk, 36.0% had a previous stress test with low-risk findings and no symptoms, and 7.3% were symptomatic/had no previous stress test/had low pretest probability. The median hospital-level inappropriateness rate was 28.5%, with a maximum of 48.8% and a minimum of 8.6%. Hospital-level inappropriateness was not related to hospital volume or inappropriateness for percutaneous coronary intervention. Conclusions— One quarter of patients undergoing DC for suspected coronary artery disease were rated as inappropriate for the procedure, approximately two thirds of these inappropriate patients had no previous stress test, and ≈90% of inappropriate patients with no previous stress test were asymptomatic with low or intermediate global risk scores.

Background— There are evidence-based guidelines for staging of patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), but we are not aware of any evidence comparing the strategy of complete revascularization (CR) with PCI in the index admission versus the strategy of staging in a subsequent admission for patients with coronary artery disease without STEMI. Methods and Results— PCI patients without STEMI undergoing PCI in New York between 2007 and 2009 were separated into 2 groups: those with acute coronary syndrome but no STEMI, and those without acute coronary syndrome. For each group, patients who underwent CR in the index admission were then propensity matched to patients staged within 60 days to obtain CR based on 17 patient risk factors related to longer-term mortality, and 3-year mortality rates were compared for the propensity-matched groups. Outcomes were also compared for preselected subgroups. For propensity-matched patients without acute coronary syndrome, the all-cause mortality rates at 3 years for patients who underwent CR in the index hospitalization and patients staged for CR within 60 days of discharge were 5.62% and 5.97%, P =0.93, respectively. For propensity-matched patients with acute coronary syndrome but without STEMI, the all-cause mortality rates at 3 years for patients who underwent CR in the index hospitalization and patients staged for CR within 60 days of discharge were 6.59% and 5.92%, P =0.41, respectively. Conclusions— Patients with coronary artery disease without STEMI do not have significantly lower 3-year mortality rates with staged PCI than when they undergo CR in the index admission.

Background— Little is known about what treatments patients receive after being diagnosed with stable coronary artery disease or what the comparative outcomes are for routine medical treatment (RMT) versus percutaneous coronary intervention (PCI) with RMT for patients in a setting apart from randomized controlled trials. Methods and Results— Patients with stable coronary artery disease undergoing cardiac catheterization in New York State between 2003 and 2008 were followed up to determine the treatment they received. Patients receiving RMT and patients receiving PCI with RMT were propensity matched through the use of 20 factors that could have a bearing on outcomes. The resulting cohort of 933 matched pairs was used to compare mortality/myocardial infarction (MI), mortality, MI, and subsequent revascularization rates. A total of 89% of all patients underwent PCI with RMT. PCI/RMT patients had significantly lower adverse outcome rates at 4 years for mortality/MI (16.5% versus 21.2%; P =0.003), mortality (10.2% versus 14.5%; P =0.02), MI (8.0% versus 11.3%; P =0.007), and subsequent revascularization (24.1% versus 29.1%; P =0.005). Adjusted RMT versus (PCI with RMT) hazard ratios were 1.49 (95% confidence interval, 1.16–1.93) for mortality/MI and 1.46 (95% confidence interval, 1.08–1.97) for mortality. There were no differences for patients ≤65 years of age or for patients with single-vessel disease. Conclusions— Most patients with stable coronary artery disease in New York undergoing catheterization between 2003 and 2008 received PCI. Patients who received PCI experienced lower mortality, mortality/MI, and revascularization rates. The reasons for this finding need to be better understood, including the possible role of low medication adherence rates that have been found in other studies.