The Impact of Excluding Shock Patients on Hospital and Physician Risk-Adjusted Mortality Rates for Percutaneous Coronary Interventions: The Implications for Public Reporting.
The authors examined the impact of including shock patients in public reporting of percutaneous coronary intervention (PCI) risk-adjusted mortality.



There is concern that an unintended consequence of statewide public reporting of medical outcomes is the avoidance of appropriate interventions for high-risk patients.



New York State's PCI registry was used to compare hospital and physician risk-adjusted mortality rates and outliers from New York's public report models with rates and outliers based on statistical models that include refractory shock patients and exclude both refractory shock and other shock patients.



Correlations between the public report model and each of the other 2 models were above 0.92 for hospital risk-adjusted rates and were 0.99 for all physician risk-adjusted rates (p < 0.0001). There were 11 physicians with lower than expected mortality rates (low outliers) and 41 physicians with higher than expected mortality rates (high outliers) across the 3 time periods in the public report, compared with 10 low outliers and 40 high outliers if all shock patients had been excluded. There was considerable overlap among outliers identified by the 3 models. Findings were similar for hospital outliers.



Risk-adjusted hospital and physician mortality rates are highly correlated regardless of whether shock patients are included in public reporting. The numbers of outliers are similar, and outlier changes are minimal, although 10% to 15% of cardiologists who were outliers in either exclusion rule were not outliers in the other one. This information can form a basis for subsequent discussions regarding the exclusion of high-risk patients from public reporting.
University at Albany, State University of New York, Albany, New York. Electronic address: edward.hannan@health.ny.gov.
Edward L
EL
Hannan
University at Albany, State University of New York, Albany, New York.
Ye
Y
Zhong
University at Albany, State University of New York, Albany, New York.
Kimberly
K
Cozzens
New York State Department of Health, Albany, New York.
Foster
F
Gesten
New York State Department of Health, Albany, New York.
Marcus
M
Friedrich
Northwell Health, Great Neck, New York.
Peter B
PB
Berger
Boston Medical Center, Boston, Massachusetts.
Alice K
AK
Jacobs
Johns Hopkins University, Baltimore, Maryland.
Gary
G
Walford
University of Rochester Medical Center, Rochester, New York.
Frederick S K
FS
Ling
Albany Medical Center, Albany, New York.
Ferdinand J
FJ
Venditti
St. Joseph's Health System, Atlanta, Georgia.
Spencer B
SB
King
D000072096:Cardiologists / Q000592:standards; D002983:Clinical Competence / Q000592:standards; D003327:Coronary Disease / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000068598:Data Accuracy; D003625:Data Collection / Q000592:standards; D017052:Hospital Mortality; D006801:Humans; D009518:New York; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality* / Q000592:standards; D017064:Process Assessment, Health Care / Q000592:standards; D019984:Quality Indicators, Health Care / Q000592:standards; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000175:diagnosis / Q000401:mortality*; D013997:Time Factors; D016896:Treatment Outcome
PCI; public reporting of outcomes; risk-adjusted mortality