By Andrew M. Seaman
NEW YORK (Reuters Health) - In what might be an unintended consequence of health care improvement efforts, older heart attack patients seem less likely to get stents in the U.S. states that require hospitals to report the outcomes of such procedures, according to a new study.
Some believe public reporting allows patients to pick the best hospitals while encouraging hospitals to perform better, according to the researchers. But some fear such reporting also discourages doctors from performing risky but necessary procedures.
"It has been discussed that public reporting was taking place, and there have been discussions at meetings about what the consequences could be," said Dr. Karen E. Joynt, the study's lead researcher and an instructor at Harvard Medical School and the Harvard School of Public Health in Boston.
Joynt and her colleagues found that among nearly 100,000 people on Medicare hospitalized for a heart attack in 2010, about 38 percent of those living in states with reporting laws had angioplasty - a procedure to open narrowed arteries. That's compared to about 43 percent of patients in states without such laws.
The study's researchers, who reported their findings in the Journal of the American Medical Association on Tuesday, say they can't tell whether the difference is from doctors forgoing needed procedures, doctors being better at selecting when to do procedures, or something else.
Three U.S. states require hospitals to report the outcomes of angioplasty, in which a balloon-tipped catheter pushes aside the blockage causing the heart attack. Sometimes, a small, mesh cylinder called a stent is inserted to keep the artery open.
New York was the first state to require hospitals to report outcomes in 1991, and was followed by Pennsylvania and Massachusetts in 2001 and 2005, respectively.
The researchers said previous studies on heart procedures and reporting are almost 20 years old, and more recent studies only compared one or two states.
For the new study, Joynt and her colleagues used a Medicare database to compare the number of angioplasties preformed in the three states that report outcomes to that of seven nearby non-reporting states: Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland and Delaware.
FEWER PROCEDURES, SAME OUTCOMES
The authors also looked at what happened before and after Massachusetts implemented its reporting law in 2005.
They found that from 2002 to 2004, rates of angioplasty were similar in Massachusetts compared to other states without laws.
However, from 2005 to 2010, the odds of a heart attack patient in Massachusetts getting angioplasty dropped compared to the same states.
The researchers wanted to see if the states where fewer stents were placed saw more people dying within 30 days of discharge. They did not.
As for why the number of angioplasties dropped between reporting and non-reporting states, Dr. Maura Moscucci, who wrote an editorial accompanying the new study, told Reuters Health that it's probably a combination of doctors forgoing risky procedures and getting better at avoiding unnecessary ones.
"Things can go both ways. This is an important step forward, but we still have questions that remain to be answered," said Moscucci, from the University of Miami Miller School of Medicine.
Joynt said there are researchers developing systems and tools for doctors to better know when to perform angioplasty on a patient, and to give credit to hospitals that take on the toughest cases.
As for now, Joynt said she hopes the results help people see how they can improve public reporting policies.
"There are a lot of states that are moving forward with public reporting, and I think transparency and accountability are not going away. Our hope is that this brings up a lot of questions," she said.
SOURCE: http://bit.ly/JOTmp1 JAMA, online October 9, 2012.