title: Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction.
abstract: 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.
authors.affiliation: Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA.
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
authors.forename: Jeph
authors.initials: J
authors.lastname: Herrin
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Mattera
authors.forename: Eric S
authors.initials: ES
authors.lastname: Holmboe
authors.forename: Yongfei
authors.initials: Y
authors.lastname: Wang
authors.forename: Paul
authors.initials: P
authors.lastname: Frederick
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Roumanis
authors.forename: Martha J
authors.initials: MJ
authors.lastname: Radford
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: 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
chemical_list: D000319:Adrenergic beta-Antagonists