Quality of Care at Outlier Hospitals and Outcomes for PCI

Study Questions:

What are the procedural management and in-hospital outcomes of patients treated for acute myocardial infarction (AMI) before and after a hospital was publicly identified as a negative outlier?


The investigators used state reports to identify hospitals that were recognized as negative PCI outliers in two states (Massachusetts and New York) from 2002-2012. State hospitalization files were used to identify all patients with an AMI 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. The authors used multivariable modified Poisson regression to examine the association of the pre- and post-report time periods with procedural management (coronary angiography/percutaneous coronary intervention (PCI)/coronary artery bypass grafting) and mortality at both outlier and nonoutlier hospitals.


Among 86 hospitals, 31 were reported as outliers for excess mortality. Outlier facilities were larger, treating more AMI patients and performing more PCIs than nonoutlier hospitals (p < 0.05 for each). Among 507,672 AMI patients 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 p-value, 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 p-value < 0.001). Among patients who underwent PCI, in-hospital mortality decreased at outlier institutions after public recognition of outlier status compared with prior (RR, 0.72; 95% CI, 0.66-0.79), a decline that exceeded the reduction at nonoutlier institutions (RR, 0.87; 95% CI, 0.80-0.96; interaction p-value < 0.001).


The authors reported that after outlier designation, in-hospital mortality declined at outlier institutions to a greater extent than was observed at nonoutlier facilities.


This study reports that in-hospital mortality among patients undergoing percutaneous revascularization was substantially lower at outlier institutions after public report of outlier status. Furthermore, the reduction in in-hospital mortality was in excess of that observed for patients treated in the same state and same time period at nonoutlier institutions. The improved clinical outcomes in the absence of enhanced risk aversion highlight the benefits of public reporting and overall transparency in the healthcare system. Additional studies are indicated to optimize patient care and improve in-hospital mortality among patients with AMI with a focus on continued quality improvement.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Coronary Angiography, Coronary Artery Bypass, Hospital Mortality, Myocardial Infarction, Myocardial Revascularization, Outcome Assessment (Health Care), Patient Care, Percutaneous Coronary Intervention, Public Policy, Quality Improvement

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