Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
JACC Cardiovasc Interv. 2013 Jun;6(6):625-30. doi: 10.1016/j.jcin.2013.01.140.
This study sought to evaluate the impact of public reporting of hospitals as negative outliers on percutaneous coronary intervention (PCI) case-mix selection.
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.
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.
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).
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.
本研究旨在评估将医院作为负异常值进行公开报告对经皮冠状动脉介入治疗（PCI）病例组合选择的影响。
PCI 后风险调整住院死亡率的公开报告旨在改善结果。然而，基于风险调整死亡率对负异常值进行公开标记可能会对医院照顾高危患者的意愿产生不利影响。
我们使用广义估计方程来检查 2003 年至 2010 年期间在马萨诸塞州所有进行 PCI 的非联邦资助医院中 116227 例 PCI 患者的预期住院死亡率。主要观察指标为确定异常值状态后每家医院的预测住院死亡率的变化。
研究期间所有 PCI 病例的加权平均预期死亡率为 1.38%±0.36%（所有休克或 ST 段抬高型心肌梗死患者为 5.3%±1.96%，所有非休克、非 ST 段抬高型心肌梗死患者为 0.58%±0.19%）。在作为负异常值机构被公开识别后，异常值机构的 PCI 患者的预测死亡率相对降低了 18%（绝对降低 0.25%）（95%置信区间：-0.04%至-0.46%，p=0.021），而非异常值机构。在整个研究期间，由于自公开报告开始以来的长期变化，马萨诸塞州所有 PCI 患者的预测死亡率风险相对降低了 37%（绝对降低 0.51%）（95%置信区间：-0.20%至-0.83%，p=0.002）。
与非异常值机构相比，异常值机构的 PCI 患者的风险状况在公开识别后显著降低，这表明马萨诸塞州的公开报告可能是异常值机构的 PCI 操作者采取避险行为的意外后果。
