Public reporting on aortic valve replacement outcomes has resulted in fewer valve surgeries for people with endocarditis, a new study has found. The researchers looked at national data from people with injection drug use and non-injection drug use-associated endocarditis and found that these patients were 30 percent less likely to receive valve surgery two years after outcomes data become public than before.
Led by researchers at Boston Medical Center's Grayken Center for Addiction and published in Clinical Infectious Diseases, the study results indicate a possible unintended consequence of public reporting of outcomes and the need to ensure that patients who require valve surgery actually receive it.
In 2013, the Society of Thoracic Surgery began publicly reporting the outcomes of aortic valve surgeries for individual surgeons and hospitals, including the risk-adjusted in-hospital and 30-day mortality and 30-day morbidity after aortic valve replacement. Data shows that of the nearly 30,000 aortic valve replacements performed each year, the in-hospital mortality for non-endocarditis replacements is less than 2 percent.
Endocarditis is a serious infection of the heart valve that frequently requires valve replacement surgery, and when indicated this surgery is associated with substantial reduction in mortality. However, valve surgery for endocarditis represents only a fraction of all valve surgeries, and the mortality and surgical complication rates for endocarditis-associated valve procedures is much higher than for those done for other reasons.
Given the mortality and morbidity related to endocarditis, we wanted to examine if the decision to have hospitals and surgeons make their outcomes data publicly reportable would impact whether or not they would do these life-saving surgeries on patients with endocarditis."
Simeon Kimmel, MD, study's lead author and addiction medicine and infectious disease fellow at Boston Medical Center
The researchers analyzed data from the National Inpatient Sample, which is a representative sample of US inpatient hospitalizations, from Jan. 2010 through Sept. 2015. They included individuals 18-65 years old who were diagnosed with endocarditis, representing 36,542 injection drug use associated endocarditis admissions and 119,316 non-injection drug use associated endocarditis admissions.
After the implementation of public data reporting for aortic valve replacements, the odds of patients receiving this surgery decreased by four percent per quarter with no difference in injection drug use status. The researchers note that the data appears to show that surgeons may be operating less because they are concerned about having bad outcomes on higher-risk cases that would then be publicly reportable.
"The intentions of making this data publicly available were to promote transparency and improve the quality of care, but our study suggests that it may have had the unintended consequence of reducing access to valve replacement surgery, a potentially life-saving procedure for people with endocarditis," added Kimmel.
The authors propose that further studies be conducted to look at the impact of mortality over the long term to better understand the impact of these changes. In addition, they suggest that changes in how endocarditis is risk-adjusted in publicly reported data might help ensure greater access to this surgery for patients with endocarditis.
Kimmel, S.D., et al. (2019) Effect of Publicly Reported Aortic Valve Surgery Outcomes on Valve Surgery in Injection Drug– and Non–Injection Drug–Associated Endocarditis. Clinical Infectious Diseases. doi.org/10.1093/cid/ciz834.