Hospitals that adopt a strategy of avoiding high-risk PCI cases in an effort to improve performance metrics may not have improved metrics, according to a study published Nov. 30 in the Journal of the American College of Cardiology.

Aswin S. Nathan, MD, MS, et al., used data from ACC’s CathPCI Registry to look at the effects of risk-avoidance strategies on hospital performance for mortality and bleeding, as well as effects on hospital rankings. The primary outcome was risk-adjusted in-hospital mortality and bleeding rates at each hospital, based on the CathPCI Registry in-hospital prediction models.

For each hospital, the researchers ranked cases based on predicted mortality or bleeding rates, removing cases in the top 10% of predicted risk for each individual hospital. Each hospital’s individual risk-adjusted mortality or bleeding rate and rank among all hospitals was then recalculated with the remaining cases, holding risk-adjusted mortality and bleeding rates constant for other hospitals. For sensitivity analyses, the calculations were repeated for the top 5% and 1% of risky cases at each hospital. Based on the registry’s risk-adjustment models, procedures were not eligible for the analysis if patients were transferred from one acute care facility to another or if their discharge status was missing.

The investigators considered 740,293 index PCI procedures performed at 1,565 hospitals. Among hospitals practicing a risk-avoidance strategy, the risk-adjusted in-hospital mortality rate decreased at 883 hospitals (56.4%) but increased at 610 hospitals (39%). Similarly, risk-adjusted bleeding rates were reduced at 843 hospitals (53.8%) but higher at 582 facilities (37.2%).

When cases at the top 5% and 1% of risk were excluded, a higher number of hospitals had lower ratings than at the 10% threshold. At the 5% threshold, 776 hospitals (49.5%) reduced their risk-adjusted morality, but 717 (45.9%) increased it. Removing the top 1% of risky cases flipped the numbers, with lower mortality rates at 547 hospitals (34.9%) but higher mortality rates at 841 hospitals (53.7%).

Risk-avoidance strategies “will ultimately harm patients,” the researchers write, noting that “patients deemed to be at high risk have the most to benefit from a potentially life-saving procedure.” Such strategies may “worsen a hospital’s metric,” they add, concluding that the findings “support offering PCI to appropriate candidates regardless of predicted risk.”

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: National Cardiovascular Data Registries, CathPCI Registry, Cardiology, Registries, Risk Adjustment, Benchmarking, Patient Discharge, Percutaneous Coronary Intervention

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