Emory University School of Medicine Michael McDaniel Emory University School of Medicine 4/12/2017

Conflicts of Interest Consultant: none Research: None

Doll. JACC CVI. Vol 10, No. 7, 2017

Slightly Higher Mortality in Outliers 2,352,174 PCI procedures from 3,760 operators RSMR=O/E Mortality Ratio x Mean Population Mortality over 5 years 2.2% % 1.5% Doll. JACC CVI. Vol 10, No. 7, 2017

Significant Instability in RSMR 2,352,174 PCI procedures from 3,760 operators Mean 1.53 years Mean 0.29 years Doll. JACC CVI. Vol 10, No. 7, 2017

Outlier Status Depends on Patient Risk 55% of High Outliers are Reclassified as Non-outliers when Emergency, Salvage, Cardiac Arrest, and Cardiogenic Shock are Excluded Doll. JACC CVI. Vol 10, No. 7, 2017

No Explanation for Higher RSMR in Outliers 2,352,174 PCI procedures from 3,760 operators Doll. JACC CVI. Vol 10, No. 7, 2017

Risk Adjusted PCI Mortality Poorly Reflects PCI Quality Highly Variable over time Depends on Inclusion/Exclusions of emergency procedures Not significantly influenced by complications or processes of care “Grading on a curve” without showing outliers are providing lower quality Did not apply to 63% of operators

Mortality after PCI is Rarely a Complication of the Procedure All PCI Mortality 2001-2009 at University of Michigan Valle. Circ Quality Outcomes. 2012; 5: 229-235

Mortality is “Risk-Adjusted” Many things not in the model Brennan. JACC CVI 2013; 6: 790-9

Reporting PCI Mortality can result in a “Risk Avoidance Creep” Resnic. JACC 2009; 53: 825-30

Lower Rates of PCI in STEMI & Shock with Public Reporting of Mortality 84,121 patients from Nationwide Inpatient Sample with AMI Waldo. JACC 2015 Mar 24;65(11):1119-26

Risk Adverse Behavior? Higher Total Adjusted AMI Mortality 84,121 patients from Nationwide Inpatient Sample with AMI Waldo. JACC 2015 Mar 24;65(11):1119-26

Risk Adverse Behavior? Lower PCI Mortality & Higher Non-PCI Mortality 84,121 patients from Nationwide Inpatient Sample with AMI Waldo. JACC 2015 Mar 24;65(11):1119-26

Risk-Adverse Behavior Starts with Advent of Public Reporting Decreased PCI in AMI in Massachusetts Joynt. JAMA. 2012; 308(14):1460-8

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