Strengthening public reporting and maintaining access to care.

ublic reporting of mortality following percutaneous coronary intervention is now mandated in 3 US states (New York, Massachusetts, and Washington) and has been associated with improvement in outcomes. However, there is evidence of growing risk aversion among percutaneous coronary intervention operators in public reporting states, manifest as avoidance of treating those critically ill patients who might benefit the most from appropriate percutaneous coronary intervention. We propose 4 incremental changes to the reporting process that will preserve the benefits of public reporting while mitigating the likelihood of high-risk case aversion, which may threaten access to life-saving care. Public reporting of risk-adjusted in-hospital mortality rates after percutaneous coronary intervention (PCI) is intended to encourage adoption of best practices and to provide transparency for patients, payers, and public health officials. 1 However, there is controversy regarding the ability of public reporting to improve patient outcomes while preserving access to care. 1 Though public reporting was originally expected to encourage educated consumerism, it has proven to have a more demon-strable effect on US physician behavior. 2 Progressive risk aversion or " case selection creep " , the withholding of appropriate PCI from the highest risk patients who stand the most to gain from such treatment but have a poor overall prognosis, has become a potential public health concern. Public reporting following PCI has been variously implemented on a state-by-state basis. Assessing the impact of such programs can be difficult, in part because public reporting in PCI is itself not a standardized concept. For example, the New Jersey Department of Public Health's current public reporting process outlines institutional PCI case volumes and performance on door-to-balloon time in primary PCI, but does not currently report mortality outcomes. Alternatively, an independent state agency in Pennsylvania previously reported mortality outcomes following PCI but has suspended doing so since 2009. In 2012, Washington State began reporting on process measures and mortality outcomes following PCI through an independent state agency after many years of central adju-dication without public reporting. However, our understanding of the impact of publicly reporting in PCI is largely driven by 2 states with arguably the most mature public reporting programs, New York and Massachusetts, both of whom report risk-adjusted mortality rates through their respective departments of public health. It is in these states that evidence of risk aversion has been most manifest. In New York State, retrospective reports have demonstrated that the proportion of patients treated …