From Department of Medicine, VA Eastern Colorado Health Care System, Denver (S.W.W.); University of Washington School of Medicine, Seattle (J.M.M.); Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Harvard School of Public Health, Boston, MA (C.M.Z.); and Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (D.S.P., R.W.Y.).
Circulation. 2017 May 16;135(20):1897-1907. doi: 10.1161/CIRCULATIONAHA.116.025998. Epub 2017 Mar 1.
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.
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.
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 (<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 =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 <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 <0.001).
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.
经皮冠状动脉介入治疗（PCI）结果的公开报告可能会使医生不愿为重症患者提供治疗，尤其是在临床结果较差的机构。因此，我们试图评估在一家医院被公认为负性外离群值后，接受急性心肌梗死治疗的患者的治疗过程管理和住院结局。
我们利用州报告，确定了 2002 年至 2012 年在马萨诸塞州和纽约州的两个州被认定为 PCI 负性外离群值的医院。利用州住院档案，确定了这些州内所有急性心肌梗死患者。比较外离群值医院在公开报告外离群值状态前后的患者的治疗过程管理和住院结局。非外离群值机构的患者用于控制时间趋势。
在 86 家医院中，有 31 家被报告为死亡率过高的外离群值医院。外离群值医院规模较大，治疗的急性心肌梗死患者和实施的 PCI 数量均多于非外离群值医院（<0.05）。在这些机构住院的 507672 例急性心肌梗死患者中，有 108428 例（21%）在公开报告后于外离群值医院接受治疗。外离群值（相对风险[RR]，1.13；95%置信区间[CI]，1.12-1.15）和非外离群值（RR，1.13；95%CI，1.11-1.14）机构行 PCI 的可能性以相似的方式增加（交互=0.50）在公开报告外离群值状态后。外离群值医院的住院死亡率降低（RR，0.83；95%CI，0.81-0.85），而非外离群值医院的死亡率降低程度较小（RR，0.90；95%CI，0.87-0.92；交互<0.001）。在接受 PCI 的患者中，与之前相比，外离群值医院在公开确认外离群值状态后住院死亡率降低（RR，0.72；9%CI，0.66-0.79），这一降幅大于非外离群值医院（RR，0.87；95%CI，0.80-0.96；交互<0.001）。
临床工作量较大的大医院更有可能被指定为负性外离群值。在报告外离群值状态后，外离群值和非外离群值机构行经皮血运重建的比例相似增加。在外离群值指定后，外离群值医院的住院死亡率下降幅度大于非外离群值医院。
