After public designation as negative PCI outliers, in-hospital mortality declined at outlier institutions (RR 0.83; 95% CI 0.81-0.85) to a greater extent than at nonoutlier facilities (P<0.001).
Observational (n=507,672)
Yes
Does public identification of hospitals as negative outliers for PCI mortality affect the likelihood of PCI and in-hospital mortality for patients with acute myocardial infarction?
Public reporting of negative outlier status for PCI mortality was associated with a greater reduction in in-hospital mortality for AMI patients at outlier hospitals compared to nonoutlier hospitals, without a disproportionate decrease in PCI rates.
Effect estimate: RR 0.83 (95% CI 0.81-0.85)
p-value: p=<0.001
Background: Public reporting of percutaneous coronary intervention (PCI) outcomes may create disincentives for physicians to provide care for critically ill patients, particularly at institutions with worse clinical outcomes. We thus sought to evaluate the procedural management and in-hospital outcomes of patients treated for acute myocardial infarction before and after a hospital had been publicly identified as a negative outlier. Methods: Using state reports, we identified hospitals that were recognized as negative PCI outliers in 2 states (Massachusetts and New York) from 2002 to 2012. State hospitalization files were used to identify all patients with an acute myocardial infarction within these states. Procedural management and in-hospital outcomes were compared among patients treated at outlier hospitals before and after public report of outlier status. Patients at nonoutlier institutions were used to control for temporal trends. Results: Among 86 hospitals, 31 were reported as outliers for excess mortality. Outlier facilities were larger, treating more patients with acute myocardial infarction and performing more PCIs than nonoutlier hospitals ( P <0.05 for each). Among 507 672 patients with acute myocardial infarction hospitalized at these institutions, 108 428 (21%) were treated at an outlier hospital after public report. The likelihood of PCI at outlier (relative risk RR, 1.13; 95% confidence interval CI, 1.12–1.15) and nonoutlier institutions (RR, 1.13; 95% CI, 1.11–1.14) increased in a similar fashion (interaction P =0.50) after public report of outlier status. The likelihood of in-hospital mortality decreased at outlier institutions (RR, 0.83; 95% CI, 0.81–0.85) after public report, and to a lesser degree at nonoutlier institutions (RR, 0.90; 95% CI, 0.87–0.92; interaction P <0.001). Among patients that underwent PCI, in-hospital mortality decreased at outlier institutions after public recognition of outlier status in comparison with prior (RR, 0.72; 9% CI, 0.66–0.79), a decline that exceeded the reduction at nonoutlier institutions (RR, 0.87; 95% CI, 0.80–0.96; interaction P <0.001). Conclusions: Large hospitals with higher clinical volume are more likely to be designated as negative outliers. The rates of percutaneous revascularization increased similarly at outlier and nonoutlier institutions after report of outlier status. After outlier designation, in-hospital mortality declined at outlier institutions to a greater extent than was observed at nonoutlier facilities.
Waldo et al. (2017) conducted an observational in acute myocardial infarction (n=507,672). Public report of negative PCI outlier status vs. Before public report and nonoutlier institutions was evaluated on In-hospital mortality (RR 0.83, 95% CI 0.81-0.85, p=<0.001). After public designation as negative PCI outliers, in-hospital mortality declined at outlier institutions (RR 0.83; 95% CI 0.81-0.85) to a greater extent than at nonoutlier facilities (P<0.001).