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

2. Conflicts of Interest
Consultant: none
Research: None

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

4. 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

5. 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

6. 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

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

8. 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

9. Mortality after PCI is Rarely a Complication of the Procedure
All PCI Mortality at University of Michigan
Valle. Circ Quality Outcomes. 2012; 5:

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

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

12. 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):

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

14. 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):

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

17. Thank You