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July 22, 2013
AHA Scientific Statement Addresses the Impact of PCI Reporting on Cardiac Resuscitation Centers
July 15, 2013—The American Heart Association (AHA) scientific statement regarding the impact of percutaneous coronary intervention (PCI) performance reporting on cardiac resuscitation centers (CRCs) was published by Mary Ann Peberdy, MD, et al on behalf of the AHA Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation. The statement is available online ahead of print in Circulation.
The purpose of this scientific statement is to describe the potential impact of including out-of-hospital cardiac arrest (OHCA) patients with ST-segment elevation myocardial infarction (STEMI) in the public reporting of PCI mortality and to make recommendations for modifications in the current outcomes-reporting procedures in this population. The recommendations included that 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 CRCs for cardiopulmonary resuscitation (CPR) for following the 2010 AHA guidelines for CPR and emergency cardiovascular care (ECC).
The statement notes that cardiac arrest (CA) may occur outside of a hospital, in a hospital, or in a catheterization laboratory during a revascularization procedure. It states that the outcome of these CAs is affected dramatically by factors such as the location of the arrest, performance of immediate high-quality CPR, the presenting rhythm, rapid defibrillation, total ischemic time, and the extent of systemic reperfusion injury. In reporting these patients, it is nearly impossible to perform adequate risk adjustment for the single variable “CA” given the diversity of this population. Therefore, CA patients should not be considered as a single category in a publicly reported outcomes database.
All registry-reported outcomes of PCI after OHCA either aggregate the various components in the chain of survival rather than reflecting the quality of emergency PCI independently or do not address the confounder of CA at all, advised the AHA scientific statement.
The AHA statement concluded that the accurate prediction of outcomes of PCI after OHCA in an effort to measure quality of PCI is difficult, if not impossible, and has the unintended consequence of hampering improvement in systems of care and the optimal use of reperfusion for patients who have had an OHCA.
The AHA scientific statement outlines the following three potential approaches to the dilemma posed by the current inclusion of OHCA in STEMI-PCI quality reporting:
1. Quality-tracking organizations could simply exclude OHCA cases from individual operator and institutional STEMI-PCI mortality reporting by categorizing these cases as compassionate use of an appropriate treatment in exceptionally high-risk patients. This approach is suboptimal because it would not permit evaluation of the quality of STEMI-PCI services and would waste the opportunity to collect data and pursue quality-improvement initiatives.
OHCA cases could be included in quality reporting if appropriate risk adjustment could be made. The problem is that current risk-adjustment models are not adequate, as noted, and given the diversity of the CA population, they are not likely to ever be adequate.
2. OHCA cases could be included in quality reporting if appropriate risk adjustment could be made. However, as noted and given the diversity of the CA population, risk adjustment models are not likely to ever be adequate.
We believe that categorizing OHCA STEMI-PCI cases separately from other STEMI-PCI cases represents the most appropriate solution, because the inclusion of OHCA patients in the public reporting of PCI outcomes does not accurately reflect quality. Therefore:
3. Our recommendation is that 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 CRCs for following the 2010 AHA Guidelines for CPR and ECC. Until an adequate risk adjustment model is created to account for the numerous out-of-hospital and in-hospital variables that impact survival more than the performance of PCI, we believe that categorizing OHCA STEMI-PCI cases separately from other STEMI-PCI cases and not including them in public reporting represents the most appropriate solution at this time.
