title: Impact of public reporting and outlier status identification on percutaneous coronary intervention case selection in Massachusetts.
abstract: OBJECTIVE
  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.
authors.affiliation: Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. mccabe@aya.yale.edu
authors.forename: James M
authors.initials: JM
authors.lastname: McCabe
authors.forename: Karen E
authors.initials: KE
authors.lastname: Joynt
authors.forename: Frederick G P
authors.initials: FG
authors.lastname: Welt
authors.forename: Frederic S
authors.initials: FS
authors.lastname: Resnic
mesh_terms: D022126:Access to Information; D003661:Decision Support Techniques; D017052:Hospital Mortality; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D019221:Mandatory Reporting; D008404:Massachusetts; D015999:Multivariate Analysis; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality*; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome