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Michael McDaniel Emory University School of Medicine 3/21/2019

Michael McDaniel Emory University School of Medicine 3/21/2019. Conflicts of Interest. None. Reimbursements are Changing. Rewarding Value instead of Volume. PCI Risk-adjusted mortality. Increasing Transparency. PCI Outcomes to be Publically Reported. Dehmer. JACC 2014; 63:1239-45.

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Michael McDaniel Emory University School of Medicine 3/21/2019

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  1. Michael McDaniel Emory University School of Medicine 3/21/2019

  2. Conflicts of Interest • None

  3. Reimbursements are Changing Rewarding Value instead of Volume • PCI Risk-adjusted mortality

  4. Increasing Transparency PCI Outcomes to be Publically Reported Dehmer. JACC 2014; 63:1239-45

  5. Increasing Transparency PCI Outcomes to be Publically Reported Dehmer. JACC 2014; 63:1239-45

  6. Cardiac Arrest and Cardiogenic Shock Drives PCI Mortality 69% 1,208,137 PCIs in NCDR 33% 25% 5.3% 0.2% Brennan. JACC CVI 2013; 6: 790-9

  7. Mortality is “Risk-Adjusted” Brennan. JACC CVI 2013; 6: 790-9

  8. Doll. JACC CVI. Vol 10, No. 7, 2017

  9. Slightly Higher Mortality in Outliers 2,352,174 PCI procedures from 3,760 operators RSMR=O/E Mortality Ratio x Mean Population Mortality over 5 years 2.2% % 1.5% Doll. JACC CVI. Vol 10, No. 7, 2017

  10. Significant Instability in RSMR 2,352,174 PCI procedures from 3,760 operators Mean 1.53 years Mean 0.29 years Doll. JACC CVI. Vol 10, No. 7, 2017

  11. Outlier Status Depends on Patient Risk55% of High Outliers are Reclassified as Non-outliers when Emergency, Salvage, Cardiac Arrest, and Cardiogenic Shock are Excluded Doll. JACC CVI. Vol 10, No. 7, 2017

  12. No Explanation for Higher RSMR in Outliers 2,352,174 PCI procedures from 3,760 operators Doll. JACC CVI. Vol 10, No. 7, 2017

  13. Risk Adjusted PCI Mortality Poorly Reflects PCI Quality • Highly Variable over time • Depends on Inclusion/Exclusions of emergency procedures • Not significantly influenced by complications or processes of care • “Grading on a curve” without showing outliers are providing lower quality • Did not apply to 63% of operators

  14. Mortality after PCI is Rarely a Complication of the Procedure All PCI Mortality 2001-2009 at University of Michigan Valle. Circ Quality Outcomes. 2012; 5: 229-235

  15. Mortality is “Risk-Adjusted” Many things not in the model Brennan. JACC CVI 2013; 6: 790-9

  16. Physicians Do Not Trust “Risk-Adjustment” in PCI Question: Do you agree or disagree that the model is sufficient to avoid penalizing physicians who perform higher-risk interventions? 85% New York Cardiologists % 13% Arch Intern Med. 2005;165(1):83-87

  17. Reporting PCI Mortality can result in a “Risk Avoidance Creep” Resnic. JACC 2009; 53: 825-30

  18. Lower Rates of PCI in STEMI & Shock with Public Reporting of Mortality 84,121 patients from Nationwide Inpatient Sample with AMI Waldo. JACC 2015 Mar 24;65(11):1119-26

  19. Lower Rates of PCI in Cardiac Arrest and Shock with Public Reporting 3 Public Reporting States Rank 31ist, 47th, & 49th In Rates of PCI for CA/Shock * * * Joynt. JAMA. 2012; 308(14):1460-8

  20. Risk Adverse Behavior?Higher Total Adjusted AMI Mortality 84,121 patients from Nationwide Inpatient Sample with AMI Waldo. JACC 2015 Mar 24;65(11):1119-26

  21. Risk Adverse Behavior?Lower PCI Mortality & Higher Non-PCI Mortality 84,121 patients from Nationwide Inpatient Sample with AMI Waldo. JACC 2015 Mar 24;65(11):1119-26

  22. Risk-Adverse Behavior Starts with Advent of Public Reporting Decreased PCI in AMI in Massachusetts Joynt. JAMA. 2012; 308(14):1460-8

  23. AHA Position Statement • “OHCA cases should be tracked but not publicly reported or used for overall PCI performance ranking, which would allow accountability for their management but would not penalize high-volume cardiac resuscitation centers.” • “These patients should not be included in public reporting.”

  24. Using RAM is Counter to the ACC’s Goals Dehmer. JACC 2014; 63:1239-45

  25. Thank You

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