Impact of Public Reporting and Outlier Status Identification on Percutaneous Coronary Intervention Case Selection in Massachusetts

Objectives This study sought to evaluate the impact of public reporting of hospitals as negative outliers on percutaneous coronary intervention (PCI) case-mix selection. Background Public reporting of risk-adjusted in-hospital mortality after PCI is intended to improve outcomes. However, public labeling of negative outliers based on risk-adjusted mortality rates may detrimentally affect hospitals' willingness to care for high-risk patients. Methods We used generalized estimating equations to examine expected in-hospital mortality rates for 116,227 PCI patients at all nonfederally funded Massachusetts hospitals performing PCI from 2003 to 2010. The main outcome measure was the change in predicted in-hospital mortality rates per hospital after outlier status identification. Results The prevalence-weighted mean expected mortality for all PCI cases during the study period was 1.38 +/- 0.36% (5.3 +/- 1.96% for all shock or ST-segment elevation myocardial infarction patients, 0.58 +/- 0.19% for all not shock, not ST-segment elevation myocardial infarction patients). After public identification as a negative outlier institution, there was an 18% relative reduction (absolute 0.25% reduction) in predicted mortality among PCI patients at outlier institutions (95% confidence interval: -0.04 to -0.46%, p = 0.021) compared with nonoutlier institutions. Throughout the study period, there was an additional 37% relative (0.51% absolute) reduction in the predicted mortality risk among all PCI patients in Massachusetts attributable to secular changes since the onset of public reporting (95% confidence interval: -0.20 to -0.83, p = 0.002). Conclusions The risk profile of PCI patients at outlier institutions was significantly lower after public identification compared with nonoutlier institutions, suggesting that risk-aversive behaviors among PCI operators at outlier institutions may be an unintended consequence of public reporting in Massachusetts. (c) 2013 by the American College of Cardiology Foundation