title: Quality improvement in coronary care: analysis of sustainability and impact on adjacent clinical measures after a Swedish controlled, multicenter quality improvement collaborative.
abstract: BACKGROUND
  Quality Improvement in Coronary Care, a Swedish multicenter, controlled quality-improvement (QI) collaborative, has shown significant improvements in adherence to national guidelines for acute myocardial infarction, as well as improved clinical outcome. The objectives of this report were to describe the sustainability of the improvements after withdrawal of study support and a consolidation period of 3 months and to report whether improvements were disseminated to treatments and diagnostic procedures other than those primarily targeted.
  
  
  RESULTS
  Multidisciplinary teams from 19 Swedish hospitals were educated in basic QI methodologies. Another 19 matched hospitals were included as blinded controls. All evaluations were made on the hospital level, and data were obtained from a national quality registry, Swedish Register of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS-HIA). Sustainability indicators consisted of use of angiotensin-converting enzyme inhibitors, lipid-lowering therapy, clopidogrel, low-molecular weight heparin, and coronary angiography. Dissemination indicators were use of echocardiography, stress tests, and reperfusion therapy; time delays; and length of stay. At the reevaluation period of 6 months, the improvements at the QI intervention hospitals were sustained in all indicators but 1 (angiotensin-converting enzyme inhibitor). Between the 2 measurements, the control group improved significantly in all but 1 indicator (angiotensin-converting enzyme inhibitor). However, at the second measurement, the absolute adherence rates of the intervention hospitals were still numerically higher in all 5 indicators, and significantly so in 1 (clopidogrel). No significant changes were observed for the dissemination indicators.
  
  
  CONCLUSIONS
  The combination of a systematic QI collaborative with a national, interactive quality registry might lead to substantial and sustained improvements in the quality of acute myocardial infarction care. However, to achieve disseminated improvements in adjacent clinical measures, those adjacent measures probably should be made explicit before any QI intervention. (J Am Heart Assoc. 2012;1:e000737 doi: 10.1161/JAHA.112.000737.).
authors.affiliation: Department of Oncology, Central Hospital,  Karlstad, Sweden (R.C.).
authors.forename: Rickard
authors.initials: R
authors.lastname: Carlhed
authors.forename: Christina
authors.initials: C
authors.lastname: Bellman
authors.forename: Mats
authors.initials: M
authors.lastname: Bojestig
authors.forename: Leif
authors.initials: L
authors.lastname: Bojö
authors.forename: Anette
authors.initials: A
authors.lastname: Peterson
authors.forename: Bertil
authors.initials: B
authors.lastname: Lindahl
keywords: acute myocardial infarction; guideline adherence; quality improvement; quality indicators; registries