Monday, October 15, 2012


We all agree that this is the digital age. Most of us have a smartphone. We serve the "net", go into facebook, answer emails, and check out stuff on Googles and Wikipedia ( sometimes even as the speaker is speaking ). As the saying goes, you can run, but you can't hide. All will be revealed. Doctors have to get use to that. Patients also can access the net, with their smartphone, tablet or laptop / desktop. They know your profile and what you have been doing. In some countries, doctors have to file their registry and work experience in the world wide web. Is that a good thing?
Well, cardiologist have taken a small lead again. In the October issue of JAMA ( Journal of the American Medical Association ), dr Karen Joynt and colleagues from Harvard University, Boston, published their findings in a paper entitled "Association of public reporting for percutaneous coronary intervention with utilization and outcomes among Medicare beneficiaries with acute myocardial infarction". In this paper, the authors revealed medical records of 49,660 patients with heart attacks. Besides dividing them into STEMI and non-STEMI patients, they also divided them into PCI done in states with public medical reporting ( PMR ) and states without public medical reporting ( NPMR ). They found that the numbers of procedures were the same in the categories of non-STEMI, Cardiogenic shock and post-MI cardiac arrest. However, in the large group of STEMI patients, the state with PMR had significantly fewer PCIs than the states with NPMR. What is more important is that this translated into a higher mortality for STEMI isn those states. In all the other categories, the outcomes in all the categories ( non-STEMI, cardioghenic shock, cardiac arrest ) were the same. Interesting? How do you explain that.
Dr Joynt and colleagues, then did a longitudinal study of their own experience in Massachusetts, where PMR began in 2005. They looked at their own states PCI rates for heart attacks, before and after 2005. They found that their AMI / PCI rates before 2005 were like the present NPMR states now. But after 2005, there were less AMI / PCI done, primarily in the category of cardiogenic shock and post MI cardiac arrest. There was however, no significant difference in outcomes reported.

If I may conclude, it looks like having procedural doctors reporting their numbers and indications for a state registry, is good, as it does cut down the numbers done. However, it may result in some categories, with higher mortality, like STEMIs in the bigger study. Interventionist will tend to guard their numbers. They will not wish to do a procedure on a high risk case which may result in a bad outcome. That would affect their rating. In some states, if their rating go down, the cath lab may be closed. We may then end up with a situation that we will all do the "safe" cases, and send all the ill ones with potentially poor outcome to the public institutions ( a certain amount is already being done now ).

I suppose, the hidden message must be that patients are more aware with what is going on nowadays. They will ask more questions and discuss their therapy with you more. Doctors must be prepared for that.



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