Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction.
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).


METHODS
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.


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


METHODS
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.
Bradley
Elizabeth H
EH
Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA.
Herrin
Jeph
J
Mattera
Jennifer A
JA
Holmboe
Eric S
ES
Wang
Yongfei
Y
Frederick
Paul
P
Roumanis
Sarah A
SA
Radford
Martha J
MJ
Krumholz
Harlan M
HM
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D017723:Drug Utilization Review / Q000706:statistics & numerical data*; D005260:Female; D006761:Hospitals / Q000145:classification / Q000592:standards*; D006801:Humans; D007857:Leadership; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000517:prevention & control; D015279:Organizational Culture; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care; D012042:Registries; D017749:Total Quality Management / Q000458:organization & administration*; D014481:United States
D000319:Adrenergic beta-Antagonists