Hospital-level performance improvement: beta-blocker use after acute myocardial infarction

Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis

BACKGROUND

Rural residents face numerous barriers to healthcare access and studies suggest poorer health outcomes for rural patients. Therefore we undertook a systematic review to determine if cardiovascular medication utilization and adherence patterns differ for rural versus urban patients.

METHODS

A comprehensive search of major electronic datasets was undertaken for controlled clinical trials and observational studies comparing utilization or adherence to cardiovascular medications in rural versus urban adults with cardiovascular disease or diabetes. Two reviewers independently identified citations, extracted data, and evaluated quality using the STROBE checklist. Risk estimates were abstracted and pooled where appropriate using random effects models. Methods and reporting were in accordance with MOOSE guidelines.

RESULTS

Fifty-one studies were included of fair to good quality (median STROBE score 17.5). Although pooled unadjusted analyses suggested that patients in rural areas were less likely to receive evidence-based cardiovascular medications (23 studies, OR 0.88, 95% CI 0.79, 0.98), pooled data from 21 studies adjusted for potential confounders indicated no rural-urban differences (adjusted OR 1.02, 95% CI 0.91, 1.13). The high heterogeneity observed (I(2) = 97%) was partially explained by treatment setting (hospital, ambulatory care, or community-based sample), age, and disease. Adherence did not differ between urban versus rural patients (3 studies, OR 0.94, 95% CI 0.39, 2.27, I(2) = 91%).

CONCLUSIONS

We found no consistent differences in rates of cardiovascular medication utilization or adherence among adults with cardiovascular disease or diabetes living in rural versus urban settings. Higher quality evidence is needed to determine if differences truly exist between urban and rural patients in the use of, and adherence to, evidence-based medications.

International comparisons of the management of patients with non-ST segment elevation acute myocardial infarction in the United Kingdom, Sweden, and the United States: The MINAP/NICOR, SWEDEHEART/RIKS-HIA, and ACTION Registry-GWTG/NCDR registries

Objectives

To compare management of patients with acute non-ST segment elevation myocardial infarction (NSTEMI) in three developed countries with national ongoing registries.

Background

Results from clinical trials suggest significant variation in care across the world. However, international comparisons in “real world” registries are limited.

Methods

We compared the use of in-hospital procedures and discharge medications for patients admitted with NSTEMI from 2007 to 2010 using the unselective MINAP/NICOR [England and Wales (UK); n = 137,009], the unselective SWEDEHEART/RIKS-HIA (Sweden; n = 45,069), and the selective ACTION Registry-GWTG/NCDR [United States (US); n = 147,438] clinical registries.

Results

Patients enrolled among the three registries were generally similar except those in the US who were younger but had higher rates of smoking, diabetes, hypertension, prior heart failure, and prior MI than in Sweden or in UK. Angiography and percutaneous coronary intervention (PCI) were performed more often in the US (76% and 44%) and Sweden (65% and 42%) relative to the UK (32% and 22%). Discharge betablockers were also prescribed more often in the US (89%) and Sweden (89%) than in the UK (76%). In contrast, discharge statins, angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB), and dual antiplatelet agents (among those not receiving PCI) were higher in the UK (92%, 79%, and 71%) than in the US (85%, 65%, 41%) and Sweden (81%, 69%, and 49%).

Conclusions

The care for patients with NSTEMI differed substantially among the three countries. These differences in care among countries provide an opportunity for future comparative effectiveness research as well as identify opportunities for global quality improvement.

The impact of a measurement and feedback intervention on blood pressure control in ambulatory cardiology practice

BACKGROUND

Although hypertension is a modifiable cardiovascular risk factor, up to one-third of ambulatory patients have uncontrolled blood pressure (BP). We evaluated the impact of a targeted provider feedback intervention on rates of BP control.

METHODS

Clinic BP readings were aggregated among approximately 3,000 hypertensive patients followed up in 42 outpatient cardiology clinic practices at a large quaternary care academic medical center. Physician practices received quarterly reports on BP control rates. Provider-specific reports were benchmarked vs overall peer performance and distributed quarterly between September 2011 and September 2012. Rates of BP control were evaluated before and after the intervention. Medical record reviews were performed for a subset of patients with uncontrolled BP before (n = 300) and after (n = 300) the intervention to evaluate provider responses and interventions.

RESULTS

At baseline, 27.9% of clinic patients had uncontrolled BP. After one 1 of reports, the rate of uncontrolled BP remained unchanged (27.7%, P = .86). Analysis of provider performance revealed a subset of providers who consistently outperform their peers. In the sample of patients selected for medical record reviews, at baseline (n = 300) and follow-up (n = 300), cardiologists discussed BP in 80% of clinic notes for patients with uncontrolled BP. Cardiologists more frequently documented repeat measurements after the intervention (28.0% vs 35.7%, P = .04). No other changes were found in documentation of provider responses to BP.

CONCLUSIONS

Clinician-specific audit and feedback reports as a stand-alone intervention did not affect overall BP control rates in cardiology clinics. Future BP control interventions should consider real-time patient-specific reminders, provider incentive programs, and patient engagement interventions.

Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction

BACKGROUND

Despite recent improvements in survival after acute myocardial infarction (AMI), U.S. hospitals vary 2-fold in their 30-day risk-standardized mortality rates (RSMRs). Nevertheless, information is limited on hospital-level factors that may be associated with RSMRs.

OBJECTIVE

To identify hospital strategies that were associated with lower RSMRs.

DESIGN

Cross-sectional survey of 537 hospitals (91% response rate) and weighted multivariate regression by using data from the Centers for Medicare & Medicaid Services to determine the associations between hospital strategies and hospital RSMRs.

SETTING

Acute care hospitals with an annualized AMI volume of at least 25 patients.

PARTICIPANTS

Patients hospitalized with AMI between 1 January 2008 and 31 December 2009.

MEASUREMENTS

Hospital performance improvement strategies, characteristics, and 30-day RSMRs.

RESULTS

In multivariate analysis, several hospital strategies were significantly associated with lower RSMRs and in aggregate were associated with clinically important differences in RSMRs. These strategies included holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital (RSMR lower by 0.70 percentage points), having cardiologists always on site (lower by 0.54 percentage points), fostering an organizational environment in which clinicians are encouraged to solve problems creatively (lower by 0.84 percentage points), not cross-training nurses from intensive care units for the cardiac catheterization laboratory (lower by 0.44 percentage points), and having physician and nurse champions rather than nurse champions alone (lower by 0.88 percentage points). Fewer than 10% of hospitals reported using at least 4 of these 5 strategies.

LIMITATION

The cross-sectional design demonstrates statistical associations but cannot establish causal relationships.

CONCLUSION

Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30-day RSMRs for patients with AMI.

PRIMARY FUNDING SOURCE

The Agency for Healthcare Research and Quality, the United Health Foundation, and the Commonwealth Fund.

Regional differences in quality of care and outcomes for the treatment of acute coronary syndromes: an analysis from the get with the guidelines coronary artery disease program

BACKGROUND

Geographic differences in the delivery of guideline-driven care following acute myocardial infarction have been described. The effect of hospital participation in a national performance improvement program on regional variation in quality of care and in-hospital outcomes for acute coronary syndromes (ACS) is unknown.

METHODS

We evaluated the variation in conformity to the American Heart Association Get With The Guidelines-Coronary Artery Disease Program quality measures across 4 geographic regions (Northeast, Midwest, South, and East) in 161,236 patients admitted for ACS to 436 Get With The Guidelines hospitals. We evaluated 6 measures (aspirin within 24 hours, aspirin at discharge, ACEI or ARB therapy for left ventricular systolic dysfunction, beta-blocker at discharge, lipid-lowering medication for qualified patients, smoking cessation advice); a binary "all-or-none" process performance measure (primary outcome); an "opportunity-based" overall composite score (secondary outcome); in-hospital length of stay, and in-hospital mortality. Multivariable logistic regression was performed to test the associations between performance measures and short-term outcomes and geographic region.

RESULTS

Data were collected from January 2, 2000 to January 2, 2008. There was no significant regional variation in either the "all-or-none" (Northeast: 79.3%; Midwest: 83.2%; South: 78.9%; West: 81.6%) or "opportunity-based" (Northeast: 91.9%; Midwest: 93.6%; South: 91.5%; West: 92.6%) composite performance measures. Both performance measures exhibited significant improvement with participation time irrespective of region. In-hospital mortality was similar among regions. Adjusted hospital length of stay was significantly shorter in the Midwest.

CONCLUSION

Quality improvement program participation may help to facilitate high quality, consistent care for patients with ACS.

Introduction to hierarchical modeling

BACKGROUND

Hierarchical modeling (HM) is a statistical technique that has gained in popularity in health care research. It has been used for analysis of secondary data, performance profiles or benchmarking studies, and in prospective trials. The technique is used in situations in which traditional regression analysis might lead to incorrect conclusions. Specifically, data drawn from nested settings such as hospital units or hospice providers may be correlated, thus violating an assumption required for ordinary least squares regression.

OBJECTIVE

This article provides a description of HM, reviews two recent articles in palliative care that have used the technique, and presents an illustrative case study to further illuminate the potential of the method.

CONCLUSION

When used appropriately, HM allows researchers to specify and test hypotheses that would not otherwise be possible, and avoid incorrect conclusions from nested data.

Characteristics and outcomes of America's lowest-performing hospitals: an analysis of acute myocardial infarction hospital care in the United States

BACKGROUND

Studies suggest that most hospitals now have relatively high adherence with recommended acute myocardial infarction (AMI) process measures. Little is known about hospitals with consistently poor adherence with AMI process measures and whether these hospitals also have increased patient mortality.

METHODS AND RESULTS

We conducted a retrospective study of 2761 US hospitals reporting AMI process measures to the Center for Medicare and Medicaid Services Hospital Compare database during 2004 to 2006 that could be linked to 2005 Medicare Part A data. The main outcome measures were hospitals' combined compliance with 5 AMI measures (aspirin and beta-blocker on admission and discharge and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use at discharge for patients with left ventricular dysfunction) and risk-adjusted 30-day mortality for 2005. We stratified hospitals into those with low AMI adherence (ranked in the lowest decile for AMI adherence for 3 consecutive years [2004-2006, n=105]), high adherence (ranked in the top decile for 3 consecutive years [n=63]), and intermediate adherence (all others [n=2593]). Mean AMI performance varied significantly across low-, intermediate-, and high-performing hospitals (mean score, 68% versus 92% versus 99%, P<0.001). Low-performing hospitals were more likely than intermediate- and high-performing hospitals to be safety-net providers (19.2% versus 11.0% versus 6.4%; P=0.005). Low-performing hospitals had higher unadjusted 30-day mortality rates (23.6% versus 17.8% versus 14.9%; P<0.001). These differences persisted after adjustment for patient characteristics (16.3% versus 16.0% versus 15.7%; P=0.02).

CONCLUSIONS

Consistently low-performing hospitals differ substantially from other US hospitals. Targeting quality improvement efforts toward these hospitals may offer an attractive opportunity for improving AMI outcomes.

Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006

BACKGROUND

Trends in the use of guideline-based treatment for acute myocardial infarction (AMI) as well as its association with patient outcomes have not been summarized in a large, longitudinal study. Furthermore, it is unknown whether gender-, race-, and age-based care disparities have narrowed over time.

METHODS AND RESULTS

Using the National Registry of Myocardial Infarction database, we analyzed 2,515,106 patients with AMI admitted to 2,157 US hospitals between July 1990 and December 2006 to examine trends overall and in select subgroups of guideline-based admission, procedural, and discharge therapy use. The contribution of temporal improvements in acute care therapies to declines in in-hospital mortality was examined using logistic regression analysis. From 1990 to 2006, the use of all acute guideline-recommended therapies administered rose significantly for patients with ST-segment elevation myocardial infarction and patients with non-ST-segment myocardial infarction but remained below 90% for most therapies. Cardiac catheterization and percutaneous coronary intervention use increased in patients with ST-segment elevation myocardial infarction and patients with non-ST-segment myocardial infarction, whereas coronary bypass surgery use declined in both groups. Despite overall care improvements, women, blacks, and patients > or =75 years old were significantly less likely to receive revascularization or discharge lipid-lowering therapy relative to their counterparts. Temporal improvements in acute therapies may account for up to 37% of the annual decline in risk for in-hospital AMI mortality.

CONCLUSION

Adherence to American Heart Association/American College of Cardiology practice guidelines has improved care of patients with AMI and is associated with significant reductions in in-hospital mortality rates. However, persistent gaps in overall care as well as care disparities remain and suggest the need for ongoing quality improvement efforts.

An organized approach to improvement in guideline adherence for acute myocardial infarction: results with the Get With The Guidelines quality improvement program

BACKGROUND

Evidence-based guidelines from the American Heart Association are voluntary, and adherence is highly variable across the country. Get With The Guidelines (GWTG) is a national quality improvement program sponsored and developed by the American Heart Association. The objective of this study was to evaluate whether participation in GWTG is associated with greater adherence to guidelines for coronary artery disease (CAD).

METHODS

Data on adherence to guidelines were obtained from Hospital Compare, grouping hospitals according to participation in the GWTG-CAD program on January 1, 2004: GWTG-CAD hospitals, n = 223; non-GWTG-CAD hospitals, n = 3407. The GWTG program uses a patient management tool, education, and benchmarked quality reports to improve guideline adherence. Adherence to 8 national measures, including the use of aspirin and beta-blockers early and at discharge and timeline reperfusion, was analyzed. A composite score was also calculated. Multivariable logistic regression was performed for comparing composite adherence rates between groups.

RESULTS

Adherence to the overall Hospital Compare composite measure was higher in GWTG-CAD hospitals than in non-GWTG-CAD hospitals (mean [SD], 89.7% [10.0%] vs 85.0 [15.0%]; absolute increase, 4.7%; P < .001). Adherence to the GWTG-CAD performance measures (PM) composite was also higher (89.5% [11.0%] vs 83.0% [18.0%]; P < .001). In multivariate analysis, GWTG-CAD participation was associated with a modest absolute increase in adherence to the PM composite by 2.52% (95% confidence interval [CI], 0.19%-4.85%). Larger acute myocardial infarction volume by quartile (absolute increase, 14.2%; 95% CI, 12.2%-16.3%), geographic location in the Northeast, and teaching hospital status (absolute increase, 2.87%; 95% CI, 0.43-5.32) were also associated with improved adherence to the PM composite. As a control, evaluation of unrelated quality measures for pneumonia, showed lower adherence among GWTG-CAD participating hospitals (74.8% [7.3%] vs 76.1% [9.7%]; P = .005).

CONCLUSION

Participation in GWTG-CAD was independently associated with improvements in guideline adherence beyond that associated with public reporting.

Hospital variation in use of secondary preventive medicine after discharge for first acute myocardial infarction during 1995-2004

OBJECTIVE

To examine temporal trends in hospital use of secondary preventive medicine after discharge for first acute myocardial infarction (AMI) in Denmark.

DESIGN

Observational study from national administrative databases of 60,339 patients who survived a first AMI at 73 acute-care hospitals during 1995-2004.

OUTCOME MEASURES

At least 1 prescription claim for angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, or statins within 90 days of discharge for AMI.

FINDINGS

The odds ratios between hospitals in the highest and lowest deciles, adjusted for age, gender, period, income, comorbidity, concomitant, and prior pharmaceutical therapy, in 1995 were 8.5 [95% confidence interval (CI), 5.5-12.2] for beta-blockers, 3.0 (2.3-3.7) for ACE inhibitors, and 6.2 (4.1-8.8) for statins. By 2004, the hospital variation had decreased for beta-blockers (3.2; 2.3-4.0) and statins (4.2; 3.0-5.5) but had increased for ACE inhibitors (3.8; 2.7-4.9). All the changes over time were significant (P < 0.001). Geographical characteristics of the hospital explained 32% of the variation in use of beta-blockers in 2004 and 27% in 1995, 39% of the variation in use of ACE inhibitors in 2004 and 3% in 1995, and 29% of the variation in use of statins and 19% in 1995.

CONCLUSIONS

Hospital use of secondary preventive medicine after discharge for AMI varied substantially. Hospital variation in use of beta-blockers and statins decreased with time whereas variation in use of ACE inhibitors increased. This may be attributed to gradually better agreement for the use of beta-blockers and statins and lesser agreement for the use of ACE inhibitors.

Use of recommended medications after myocardial infarction in Austria

Guidelines recommend long-term use of beta-blockers (BB), statins, and angiotensin-converting-enzyme-inhibitors or angiotensin-receptor-blockers (ACEI/ARB) after myocardial infarction (MI), but data on their use after discharge are scarce. From Austrian sickness funds claims, we identified all acute MI patients who were discharged within 30 days and who survived >or=120 days after MI in 2004. We ascertained outpatient use of ACEI/ARBs, BBs, statins, and aspirin from all filled prescriptions between discharge and 120 days post MI. Comorbidities were ascertained from use of indicator drugs during the preceding year. Multivariate logistic regression was used to evaluate the independent determinants of study drug use. We evaluated 4,105 MI patients, whose mean age was 68.8 (+/-13.2) years; 59.5% were men. Within 120 days after MI, 67% filled prescriptions for ACE/ARBs, 74% for BBs, and 67% for statin. While 41% received all these classes and 34% two, 25% of patients received only one or none of these drugs. Older age and presence of severe mental illness were associated with lower use of all drug classes. Diabetics had greater ACEI/ARB use. Fewer BBs were used in patients with obstructive lung disease. Statin use was lower in patients using treatment for congestive heart failure (all P<0.001). We conclude that recommended medications were underused in Austrian MI survivors. Quality indicators should be established and interventions be implemented to ensure maximum secondary prevention after MI.

The impact of emergency department structure and care processes in delivering care for non-ST-segment elevation acute coronary syndromes

BACKGROUND

We sought to assess the influence of emergency department (ED) structure and care processes on adherence to practice guidelines for the treatment of patients with non-ST-segment elevation acute coronary syndromes.

METHODS

We surveyed emergency physicians and nurses from 316 hospitals participating in the CRUSADE Quality Improvement Initiative and used multivariable modeling to correlate ED-specific characteristics with guidelines adherence.

RESULTS

Factors that were significantly associated with improved guidelines adherence included collaboration between emergency physicians and hospital administration, northeast region, adequate nursing support, use of locum tenens physicians, an independent ED (not a division of another clinical department), and use of a care algorithm for acute coronary syndromes.

CONCLUSIONS

Quality improvement strategies that have the full support of hospital administration, focus on increasing collaboration between emergency physicians and other health care providers, and specified protocol-driven management algorithm may be the most successful methods for improving the care and outcomes of patients with non-ST-segment elevation acute coronary syndromes.

Duration of hospital participation in a nationwide stroke registry is associated with improved quality of care

BACKGROUND

There are several proven therapies for patients with ischemic stroke or transient ischemic attack (TIA), including prophylaxis of deep venous thrombosis (DVT) and initiation of antithrombotic medications within 48 h and at discharge. Stroke registries have been promoted as a means of increasing use of such interventions, which are currently underutilized.

METHODS

From 1999 through 2003, 86 U.S. hospitals participated in Ethos, a voluntary web-based acute stroke treatment registry. Detailed data were collected on all patients admitted with a diagnosis of TIA or ischemic stroke. Rates of optimal treatment (defined as either receipt or a valid contraindication) were examined within each hospital as a function of its length of time in registry. Generalized estimating equations were used to adjust for patient and hospital characteristics.

RESULTS

A total of 16,301 patients were discharged with a diagnosis of stroke or TIA from 50 hospitals that participated for more than 1 year. Rates of optimal treatment during the first 3 months of participation were as follows: 92.5% for antithrombotic medication within 48 h, 84.6% for antithrombotic medications at discharge, and 77.1% for DVT prophylaxis. Rates for all treatments improved with duration of participation in the registry (p < 0.05), with the most dramatic improvements in the first year.

CONCLUSION

In a large cohort of patients with stroke or TIA, three targeted quality-improvement measures improved among hospitals participating in a disease-specific registry. Although the changes could be attributed to interventions other than the registry, these findings demonstrate the potential for hospital-level interventions to improve care for patients with stroke and TIA.

Achieving Rapid Door-To-Balloon Times

BACKGROUND

Fewer than half of patients with ST-elevation acute myocardial infarction (STEMI) are treated within guideline-recommended door-to-balloon times; however, little information is available about the approaches used by hospitals that have been successful in improving door-to-balloon times to meet guidelines. We sought to characterize experiences of hospitals with outstanding improvement in door-to-balloon time during 1999-2002.

METHODS AND RESULTS

We performed a qualitative study using in-depth interviews (n=122) with clinical and administrative staff at 11 hospitals that were participating with the National Registry of Myocardial Infarction and had median door-to-balloon times of < or =90 minutes during 2001-2002, representing substantial improvement since 1999. Data were organized with the use of NUD-IST 4 (Sage Publications Software) and were analyzed by the constant comparative method of qualitative data analysis. Eight themes characterized hospitals' experiences: commitment to an explicit goal to improve door-to-balloon time motivated by internal and external pressures; senior management support; innovative protocols; flexibility in refining standardized protocols; uncompromising individual clinical leaders; collaborative teams; data feedback to monitor progress and identify problems and successes; and an organizational culture that fostered resilience to challenges or setbacks in improvement efforts.

CONCLUSIONS

Several themes characterized the experiences of hospitals that had achieved notable improvements in their door-to-balloon times. By distilling the complex and diverse experiences of organizational change into its essential components, this study provides a foundation for future efforts to elevate clinical performance in the hospital setting.

Drug utilization review across jurisdictions – a reality or still a distant dream?

OBJECTIVE

There is a perception that many drug usage evaluations do not widely influence prescribing behaviour. The aim of this study was to critically evaluate recent journal articles which fit the Medline definition for Drug Utilization Review (DUR) and which also cover multiple healthcare sites.

METHODS

PubMed (National Library of Medicine, NLM) (2003, 2004) was searched using the MeSH topic 'drug utilization'. Retrieved studies were evaluated to ascertain those describing a DUR (measuring drug use against specific criteria). These were subdivided according to whether the DUR was conducted at one site or across many. The multi-centre DURs were critically reviewed, including evaluating whether all phases of a quality cycle were completed and determining aspects of design such as whether the study was prospective or retrospective, any interventions conducted and provision of feedback.

RESULTS

A total of 646 unique articles were retrieved. Of these, 495 (77%) did not meet the definition for DUR, while 151 (23%) articles did. Thirty-five (5%) described English language multi-centre DURs; ethics approval was obtained in ten of these and 18 were carried out retrospectively. In all 35 studies some comparator or standard was used, but only eight conducted an intervention and only three provided feedback to the prescribers.

CONCLUSION

Most DURs were not conducted across a number of centres. Of the recent published multi-centre DURs most presented only an initial audit and did not complete the quality cycle with feedback, intervention and re-audit. To widely influence prescribing behaviour, the full cycle is required with involvement of as many sites as possible to achieve improvements across many jurisdictions.

A multistate comparison of patient characteristics, outcomes, and treatment practices in acute myocardial infarction

The primary purpose of this study was to examine variations in patient characteristics, outcomes, and treatment practices in acute myocardial infarction (AMI) across 11 states. Data from 11 states were extracted from the Healthcare Cost and Utilization Project State Inpatient Dataset. Patients who had a primary diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification, code 410.x1) from 11 states were extracted from the Healthcare Cost and Utilization Project 1999 dataset. Bivariate comparisons were conducted to examine the characteristics, treatment practices, and outcomes of patients who had AMI. Multivariate regression models were used to examine the association between geographic location (and other factors) and the likelihood of in-hospital mortality, undergoing coronary artery bypass grafting (CABG), or percutaneous coronary interventions (PCIs). Results revealed considerable variations across states in practice patterns and treatment outcomes. New York had the highest average length of stay (8.2 days, p <0.01), rate of patients who had AMI being transferred (20.7%, p <0.01), and in-hospital case fatality rate (10.7%, p <0.01) and the lowest rate of alive discharges being routine (65.6%, p <0.01). PCI was performed 2 times as often as CABG for patients who had AMI (23.9% vs 11.3%, p <0.01), with patients who underwent CABG being transferred more often. Multivariate analyses showed that state of residence, age, female gender, transfer status, and number of co-morbidities were predictors of in-hospital mortality and the likelihood of undergoing CABG or PCI. In conclusion, large differences in practice patterns and treatment outcomes exist across states.

Hospital Variation in Mortality After First Acute Myocardial Infarction in Denmark From 1995 to 2002

BACKGROUND

This study used linked data from the National Hospital Registry to determine the factors that contribute to differences between hospitals in all-cause mortality after first acute myocardial infarction (AMI) between 1995 and 2002.

METHODS

The study included 64,321 patients with their first admission for AMI between 1995 and 2002 and surviving the day of admission. Multilevel logistic regression was used to determine the relationships between regional and hospital characteristics and 28-day and 365-day mortality after adjusting for individual characteristics, period, and medical history.

RESULTS

Tertiary cardiac care centers (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.67-0.96) and main regional hospitals (OR, 0.90; 95% CI, 0.80-0.99) had improved 28-day mortality compared with local hospitals. A 2-fold increase in annual total MI volume decreased 28-day mortality (OR, 0.91; 95% CI, 0.87-0.94) and 365-day mortality (OR, 0.95; 95% CI, 0.91-0.98). Differences between hospitals were more substantial for short-term mortality, such that patients were about twice as likely to die within 28 days in hospitals with the worst performance versus those with the best performance. Higher regional AMI incidence was associated with lower mortality before 2000; this disappeared after 2000. Other regional contextual characteristics had very modest effects on mortality.

CONCLUSIONS

Type of hospital, and especially total MI volume at the hospital level, were significantly associated with mortality after AMI. Individual hospitals varied substantially in both short- and long-term mortality.

From adversary to partner: have quality improvement organizations made the transition?

OBJECTIVE

To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement.

DATA SOURCE

Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002.

STUDY DESIGN

We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness.

PRINCIPLE FINDINGS

More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one-quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators.

CONCLUSIONS

Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians.

Quality Improvement Efforts and Hospital Performance

BACKGROUND

Hospitals are under increasing pressure to measure and improve quality of care, and substantial resources are being directed at a variety of quality improvement strategies; however, the evidence base supporting these strategies is limited.

OBJECTIVE

We sought to identify quality improvement efforts that were associated with hospitals' beta-blocker prescription rates after acute myocardial infarction (AMI).

RESEARCH DESIGN

This was a cross-sectional study using data from a telephone survey of quality management directors at participating hospitals linked with patient-level data from the National Registry of Myocardial Infarction (NRMI) during the study period, October 1997 to September 1999.

SUBJECTS

A total of 60,363 patients discharged with a confirmed AMI from 234 US hospitals were included.

MEASURES

Hospital performance based on beta-blocker rates characterized as the top 20%, lower 20%, and middle 40% of hospitals; reported quality improvement efforts, including system interventions, physician leadership, administrative support for quality improvement efforts, and data feedback; hospital teaching status, AMI volume, geographic location, and ownership type.

RESULTS

The mean hospital-specific beta-blocker rate was 60.2%; however, the variation in beta-blocker use across hospitals was marked (range, 19.4-89.3%, standard deviation, 12.7% points), and quality improvement efforts used varied greatly. None of the quality improvement efforts distinguished higher from medium performers; the higher and the medium performers together were distinguished from the lower performers in organizational support for quality improvement efforts (fully adjusted odds ratio [OR] 1.89, 95% confidence interval [CI] 1.17-3.06) and physician leadership (fully adjusted OR 9.88, 95% CI 2.64-37.02). Among the specific quality improvement interventions, only standing orders were associated with having higher/medium versus lower performance, and their effect had borderline significance (fully adjusted OR 2.26, 95% CI 0.97-5.30, P = 0.07).

CONCLUSIONS

Our findings highlight the organizational environment, specifically the absence of administrative support or physician leadership for quality improvement, as an important correlate of poor beta-blocker rates after AMI. Future studies are needed to isolate hospital quality improvement efforts that are associated with superior performance.