The Complicated Calculus of Publicly Reporting Mortality After Percutaneous Coronary Intervention.

Withtransparencytoutedasafundamentalcomponentofquality improvement inanemergingeraofvalue-basedhealthcare, the call for increased reporting of procedural outcomes is burgeoning. Public reporting of coronary revascularization outcomes has been available inseveral states forseveraldecades, and there are proposals to expand itmorebroadly. Fundamentally, the interest in public reporting reflects adesire to both improve and incentivize high-quality care. Another purported benefit is to assist patients in the selection of physicians andhospitals.However, forpublic reportingofprocedural outcomes to be useful, it is imperative that the measure—in this case mortality—be homogeneously representative of overall procedural quality. Furthermore, “unintended consequences” must be addressed when advocating for public reporting as an essential component of value-based health care. In this issue of JAMACardiology, 2 analyses1,2 aim to shed further light onapotential dark sideofpublic reporting. These articles address the underutilization of percutaneous coronary intervention (PCI) andcoronary revascularization insome of themost critically ill patientswhomerit coronary revascularization: patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS). By indirectly comparingproceduralutilizationandoutcomesamongstateswithand without public reporting, these analyses demonstrate consistently lower rates of PCI and revascularization for AMI-CS betweena reportingstate (NewYork)andnonreportingstates (eg, Michigan, California, and New Jersey). Although these stateto-state comparisons can be confounded by overall case selection, the findings were robust to statistical adjustment. In addition, these analyses examined the effect of a specific policy change instituted by NewYork tomitigate the observed aversion to perform procedures for high-risk patients with AMI-CS. In response to a review of statewide data, New York began to exclude patients with CS from public reporting of procedural outcomes in 2006.The authors1,2 of both analyses indirectly assessed the effect of this policy by examining the temporal trends of revascularization for AMI-CS between NewYork andother control states.Notably, the rates of revascularization forAMI-CS increasedandmortality forAMI-CSdeclined over time in all states included in the analysis. However, in one analysis,1 the increase in PCI for AMI-CS within New York still lagged behind that of the primary nonreporting stateused for comparativepurposes (Michigan). In the secondanalysis,2 adifference-in-difference analysis3wasused to compare New York data with pooled data from one reporting statewithout a shock exclusion (Massachusetts) and 3 nonreporting states (Michigan, New Jersey, and California). In this second report, the increase in PCI within NewYorkwasmore pronounced after 2006 compared with the pool of comparator states accounting for trends over time. How should we place these new data in the context of a more global conversation on the relative benefits and harms of public reporting of mortality following PCI? In contrast to theearlydaysof coronaryangioplasty,PCI is increasinglybeing performed as an outpatient procedure,4 with excellent outcomes in all but a very small number of patients (overallmortality<5%). Inadetailedanalysis5of thespecific causesofdeath followingPCIduringa9-yearperiodat theUniversityofMichigan, more than 90% of deaths following PCI were adjudicated to beunrelated to the quality of theprocedure andwere mostly or entirely due to patient characteristics (and were thereforeunpreventable). This finding resonateswith theproceedings of quality assurance meetings that take place more broadly in catheterization laboratories across the country, where deaths that can be directly attributed to a PCI-related complication are far outnumbered by deaths due to the underlying clinical presentation of the patient (eg,withAMI-CS, anoxic brain injury following cardiac arrest and comorbidities precluding surgical revascularization). Thus, the majority of patients included inmost PCI registries are at a low risk for serious adverse events such as mortality, with few patients falling in intermediateandhigh-risk ranges associated with indications such as AMI-CS.6 Understanding this almost bimodal heterogeneity in case mix is important to reflecting onwhypublic reporting ofmortality in PCI could lead to risk aversion if it fails to specifically address high-risk clinical scenarios. Fundamentally, this was whyNewYork introducedtheCSexclusion in2006givengrowing consensus that PCI can represent 2 dramatically different types of procedures: elective PCI and PCI for high-risk conditions, such as AMI-CS. If the cases performed by a physician typically include a majority of patients with negligible mortality aggregated with only a small proportion of patients for whommortalitymay be up to 50% (themortality of AMI-CS), the rate of mortality that is then publicly reported, even following risk adjustment,will disproportionately be affectedby AMI-CS or other extreme-risk patient scenarios in which the physicians may have little control over outcomes. In some ways, we have conflated reporting on the procedure with reporting on the condition. It is akin to describing outcomes for a colon resection regardless ofwhether the indicationwas for a gunshot wound to the abdomen, diverticulosis, or a large high-risk polyp. The New York shock exclusion introduced in 2006 is one clear way of dissociating these extreme-risk scenarios from the general calculation of PCI mortality and is supported in a recent position statement from the American College of Cardiology’s Interventional Council and Board of Governors.7 However, the consistent finding that rates of revascularization for Author Audio Interview at jamacardiology.com