title: Characteristics and outcomes of America's lowest-performing hospitals: an analysis of acute myocardial infarction hospital care in the United States.
abstract: 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.
  
  
  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.
authors.affiliation: Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center, Iowa City, Iowa, USA. Ioana-popescu@uiowa.edu
authors.forename: Ioana
authors.initials: I
authors.lastname: Popescu
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Werner
authors.forename: Mary S
authors.initials: MS
authors.lastname: Vaughan-Sarrazin
authors.forename: Peter
authors.initials: P
authors.lastname: Cram
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D016208:Databases, Factual; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006761:Hospitals / Q000592:standards* / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D006278:Medicare / Q000706:statistics & numerical data; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D010351:Patient Discharge; D011787:Quality of Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States / Q000453:epidemiology
chemical_list: D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors