title: Implications of Public Reporting of Risk-Adjusted Mortality Following Percutaneous Coronary Intervention: Misperceptions and Potential Consequences for High-Risk Patients Including Nonsurgical Patients.
abstract: Assessment of clinical outcomes such as 30-day mortality following coronary revascularization procedures has historically been used to spur quality improvement programs. Public reporting of risk-adjusted outcomes is already mandated in several states, and proposals to further expand public reporting have been put forward as a means of increasing transparency and potentially incentivizing high quality care. However, for public reporting of outcomes to be considered a useful surrogate of procedural quality of care, several prerequisites must be met. First, the reporting measure must be truly representative of the quality of the procedure itself, rather than be dominated by other underlying factors, such as the overall level of illness of a patient. Second, to foster comparisons among physicians and institutions, the metric requires accurate ascertainment of and adjustment for differences in patient risk profiles. This is particularly relevant for high-risk clinical patient scenarios. Finally, the potential deleterious consequences of public reporting of a quality metric should be considered prior to expanding the use of public reporting more broadly. In this viewpoint, the authors review in particular the characterization of high-risk patients currently treated by percutaneous coronary interventional procedures, assessing the adequacy of clinical risk models used in this population. They then expand upon the limitations of 30-day mortality as a quality metric for percutaneous coronary intervention, addressing the strengths and limitations of this metric, as well as offering suggestions to enhance its future use in public reporting.
authors.affiliation: University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Anuj
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Yeh
authors.affiliation: Mount Sinai Saint Luke's Hospital, New York, New York.
authors.forename: Jacqueline E
authors.initials: JE
authors.lastname: Tamis-Holland
authors.affiliation: University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Shalin H
authors.initials: SH
authors.lastname: Patel
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Guyton
authors.affiliation: Rush Medical College, Chicago, Illinois.
authors.forename: Lloyd W
authors.initials: LW
authors.lastname: Klein
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Tanveer
authors.initials: T
authors.lastname: Rab
authors.affiliation: Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York. Electronic address: akirtane@columbia.edu.
authors.forename: Ajay J
authors.initials: AJ
authors.lastname: Kirtane
mesh_terms: D000068598:Data Accuracy; D006801:Humans; D019221:Mandatory Reporting; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality*; D017064:Process Assessment, Health Care; D011639:Public Opinion; D019984:Quality Indicators, Health Care; D020379:Risk Adjustment; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: CABG; National Cardiovascular Data Registry; PCI; RAMR; cardiac arrest; high risk; mortality; public reporting; shock