Elizabeth H. Bradley, PhD; Leslie A. Curry, PhD, MPH; Erica S. Spatz, MD, MHS; Jeph Herrin, PhD; Emily J. Cherlin, MSW, PhD; Jeptha P. Curtis, MD; Jennifer W. Thompson, MPP; Henry H. Ting, MD, MBA; Yongfei Wang, MS; Harlan M. Krumholz, MD, SM
Acknowledgment: The authors thank Marcia Mulligan, David Nock, Raymond Luhn, and Morgan Nederhood for their exceptional contribution to data collection for this study.
Grant Support: By the Agency for Healthcare Research and Quality (R01-HS0-16929), the United Health Foundation, and the Commonwealth Fund. Dr. Krumholz was supported by grant U01 HL105270-02 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2034.
Reproducible Research Statement:Study protocol: Available from Dr. Cherlin (e-mail, mailto:email@example.com). Statistical code: Available from Dr. Herrin (e-mail, mailto:firstname.lastname@example.org). Data set: Not available.
Requests for Single Reprints: Elizabeth H. Bradley, PhD, 60 College Street, PO Box 208034, New Haven, CT 06520-8034; e-mail, mailto:email@example.com.
Current Author Addresses: Drs. Bradley and Curry: 60 College Street, PO Box 208034, New Haven, CT 06520-8034.
Dr. Spatz: 330 Cedar Street, FMP 310, New Haven, CT 06520-8017.
Dr. Herrin: PO Box 2254, Charlottesville, VA 22902.
Dr. Cherlin: 2 Church Street South, Suite 409, New Haven, CT 06520.
Dr. Curtis: Yale University School of Medicine, PO Box 208017, New Haven, CT 06520-8017.
Ms. Thompson: 280 Harvard Street, Apartment 5B, Cambridge, MA 02139.
Dr. Ting: 200 First Street SW, Rochester, MN 55905.
Mr. Wang and Dr. Krumholz: 1 Church Street, Suite 200, New Haven, CT 06510.
Author Contributions: Conception and design: E.H. Bradley, L.A. Curry, H.M. Krumholz.
Analysis and interpretation of the data: E.H. Bradley, L.A. Curry, J. Herrin, J.W. Thompson, H.H. Ting, Y. Wang, H.M. Krumholz.
Drafting of the article: E.H. Bradley, L.A. Curry, J. Herrin, H.M. Krumholz.
Critical revision of the article for important intellectual content: E.H. Bradley, L.A. Curry, J. Herrin, E.J. Cherlin, J.W. Thompson, E.S. Spatz, J.P. Curtis, H.H. Ting, Y. Wang, H.M. Krumholz.
Final approval of the article: E.H. Bradley, L.A. Curry, E.S. Spatz, J. Herrin, E.J. Cherlin, J.P. Curtis, J.W. Thompson, H.H. Ting, Y. Wang, H.M. Krumholz.
Statistical expertise: J. Herrin, Y. Wang.
Obtaining of funding: E.H. Bradley, H.M. Krumholz.
Administrative, technical, or logistic support: E.J. Cherlin, J.W. Thompson.
Collection and assembly of data: J. Herrin, J.W. Thompson, Y. Wang.
Bradley EH, Curry LA, Spatz ES, Herrin J, Cherlin EJ, Curtis JP, et al. Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction. Ann Intern Med. 2012;156:618-626. doi: 10.7326/0003-4819-156-9-201205010-00003
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Published: Ann Intern Med. 2012;156(9):618-626.
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.
To identify hospital strategies that were associated with lower RSMRs.
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.
Acute care hospitals with an annualized AMI volume of at least 25 patients.
Patients hospitalized with AMI between 1 January 2008 and 31 December 2009.
Hospital performance improvement strategies, characteristics, and 30-day RSMRs.
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.
The cross-sectional design demonstrates statistical associations but cannot establish causal relationships.
Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30-day RSMRs for patients with AMI.
The Agency for Healthcare Research and Quality, the United Health Foundation, and the Commonwealth Fund.
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Cardiology, Hospital Medicine, Acute Coronary Syndromes.
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