Reductions in the CABG mortality rate after the publication of such report cards in New York were encour- aging,742,750 752 but subsequent studies revealed comparable reductions in other states, regions, and countries that used confidential feedback with or without performance improvement initiatives.752 754 These findings suggest that the common de- nominator among successful performance improvement strate- gies is the implementation of a formal quality assessment and feedback program benchmarked against regional or national results.755 The incremental value of public (as opposed to confidential) reporting is controversial. Although providers fear the potential negative impact of public reporting on referrals and market share, this concern seems to be unfounded.756 765 Even when such impact has been observed, it has generally been modest, transient, and limited to areas populated by more affluent and educated subjects.760 762,766 With implementation of healthcare reform legislation that increases access of consumers and payers to objective data and more easily understood data presentations, the influence of public report cards is likely to increase in the future.762,767 771 As this occurs, it will be important to monitor unintended negative consequences, such as gaming of the reporting system772 and avoidance of high-risk patients (risk aversion), the precise group of patients who are most likely to benefit from aggressive intervention.773 776 Methodological considerations are important for provider profiling and public reporting. Numerous studies have shown the superiority of clinical over administrative data for these purposes.728 731,733,734 The latter data lack critical clinical variables that are necessary for adequate risk adjust- ment,732,735 they may confuse comorbidities and complica- tions, and they may contain inaccurate case numbers and mortality rates. 