Flawed Federal Metric may Discourage Lifesaving Stroke Care, UCLA Study finds
A widely used federal hospital safety metric is fundamentally flawed when applied to emergency stroke care, possibly creating incentives that may discourage hospitals from performing lifesaving procedures for the sickest patients, according to a new study from UCLA.
The research, published in the Journal of NeuroInterventional Surgery, examined Patient Safety Indicator 04 (PSI 04), a “failure-to-rescue” measure developed by the U.S. Agency for Healthcare Research and Quality (AHRQ) to track deaths following treatable complications in surgical patients. The study analyzed data from the Nationwide Inpatient Sample, encompassing 73,580 stroke thrombectomy procedures between 2016 and 2019, alongside detailed reviews of consecutive cases at UCLA.
While researchers affirmed the metric’s appropriateness for elective procedures performed on relatively healthy patients, thay discovered it is unsuitable for endovascular thrombectomy – an emergency procedure to remove blood clots from the brain. the study highlights the impact of hospital quality ratings, and pay-for-performance programs by Medicare and influential organizations like the Leapfrog group.
The UCLA team’s analysis revealed a stark disparity: PSI 04 occurred in 20.5% of stroke thrombectomy patients nationally, a rate one to three orders of magnitude higher than the other 17 patient safety indicators (median: 0.10%). The rate for stroke procedures was also considerably higher than the 14.3% rate observed for all surgical procedures combined.Furthermore, PSI 04 for all procedures had by far the highest event rate among the 18 federal patient safety indicators, suggesting a fundamental issue with the metric’s design.
A deeper dive into cases at UCLA’s Complete Stroke Center further substantiated these findings. Researchers examined every thrombectomy case flagged by PSI 04 between 2016 and 2018. An expert panel of neurointerventionalists and neurologists reviewed each case and determined that all patient deaths were related to complications stemming from the severe presenting stroke, not the thrombectomy procedure itself. EVT procedures accounted for 7.2% of neurosurgical PSI 04 flags despite representing only 1.5% of neurosurgical procedures, and not a single case represented an actual preventable safety concern.
The study authors pinpointed two key reasons for the metric’s flaws when applied to stroke thrombectomy. First, the tracked complications are common consequences of severe strokes, not the procedure. patients arriving with massive strokes are inherently at high risk for pneumonia, blood clots, and other complications, nonetheless of treatment. Second,stroke patients are already critically ill before the procedure,unlike those undergoing elective surgeries. Even when complications arise, these gravely ill patients have significantly less resilience to survive them compared to relatively healthy surgical patients.
“We’re essentially penalizing hospitals for trying to save patients who are already dying from stroke,” Dr. Reider-Demer stated. “These procedures give severely affected patients their only chance at survival or functional recovery,but the current metric makes it look like the hospitals are providing poor care.”
The researchers cautioned that inappropriate safety metrics can create harmful incentives. Previous research has demonstrated that public reporting of surgical mortality rates led some heart surgeons to selectively treat healthier patients to protect their performance ratings, thereby limiting access to care for the sickest individuals who need it most. “There’s a real concern that hospitals might be discouraged from performing thrombectomy on the most severe stroke patients, or that stroke centers with high volumes of critically ill patients could be unfairly penalized in quality ratings and reimbursement,” said Dr. Jeffrey Saver, the study’s senior author and vice chair for Clinical Research at UCLA Health. This concern is amplified by recent clinical trials expanding thrombectomy eligibility to patients with even larger strokes,who have higher mortality rates even with intervention,though still lower than without it.
Though, a path forward is emerging.The Centers for Medicare & Medicaid Services has proposed revising PSI 04 to exclude patients with acute conditions like stroke coded as the principal reason for admission, with implementation planned for fiscal year 2027. Dr. Saver believes this revision addresses critical shortcomings. “This revision makes sense from a clinical outlook,” he said. “The current metric doesn’t identify preventable events in stroke care and has the potential to mislead the public about hospital quality while creating incentives that could harm the sickest patients.”
