Small Changes Lead to Minimal Impact
This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.
- brain injury
- coronary angiography
- heart arrest
- percutaneous coronary intervention
- public policy
Public reporting policies have been implemented based, in part, on the belief that hospitals and providers will improve processes of care in response to the awareness of being observed (the Hawthorne effect) while simultaneously assuming that access to care will remain constant. Unfortunately, several reports have emerged, suggesting that public reporting may influence clinical treatment decisions and lead to avoidance of high-risk patients.1–3 Physicians in public reporting environments fear being labeled as negative outliers and express concern that current risk-adjustment models are inadequate to account for patients at the extremes of risk. In response to these concerns, regulators in some states have modified existing public reporting policies by introducing exceptions for uniquely high-risk patients. For example, in 2006, the New York State Department of Public Health began censoring patients with refractory cardiogenic shock from analysis of operator mortality after percutaneous coronary intervention (PCI). This resulted in an increase in rates of coronary angiography and PCI and overall decline in mortality of patients presenting with cardiogenic shock.4 In 2010, New York began censoring patients with cardiac arrest complicated by anoxic brain injury who subsequently died. The impact of this policy change had until now been unstudied.
See Article by Strom et al
In this issue of Circulation: Cardiovascular Interventions, Strom et al5 report their evaluation of the impact of excluding patients with anoxic brain injury after cardiac arrest from analysis of operator PCI mortality in the New York State public report. This retrospective, observational study used administrative claims data from State Inpatient Databases for New York and additional comparator states between 2003 and 2013 to compare rates of coronary angiography, revascularization, and mortality in patients with cardiac arrest after acute myocardial infarction (AMI) before and after introduction of the 2010 exclusion rule. Comparator states were …