The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |


Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction

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; and Harlan M. Krumholz, MD, SM
[+] Article, Author, and Disclosure Information

From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut, and Mayo Clinic, Rochester, Minnesota.

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:emily.cherlin@yale.edu). Statistical code: Available from Dr. Herrin (e-mail, mailto:jeph.herrin@yale.edu). 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:elizabeth.bradley@yale.edu.

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.

Ann Intern Med. 2012;156(9):618-626. doi:10.7326/0003-4819-156-9-201205010-00003
Text Size: A A A

Background: 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.

Objective: To identify hospital strategies that were associated with lower RSMRs.

Design: 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.

Setting: Acute care hospitals with an annualized AMI volume of at least 25 patients.

Participants: Patients hospitalized with AMI between 1 January 2008 and 31 December 2009.

Measurements: Hospital performance improvement strategies, characteristics, and 30-day RSMRs.

Results: 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.

Limitation: The cross-sectional design demonstrates statistical associations but cannot establish causal relationships.

Conclusion: Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30-day RSMRs for patients with AMI.

Primary Funding Source: The Agency for Healthcare Research and Quality, the United Health Foundation, and the Commonwealth Fund.


Grahic Jump Location

Frequency distribution for 30-day RSMR for AMI among study hospitals.

AMI = acute myocardial infarction; RSMR = risk-standardized mortality rate.

Grahic Jump Location




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
A Strategy that Works
Posted on May 10, 2012
Jeffrey C, Trost, Assistant Professor of Medicine, Sammy Zakaria, Marlene Williams, and Nisha Chandra
Johns Hopkins University Division of Cardiology, Johns Hopkins Bayview Medical Center
Conflict of Interest: None Declared

Corresponding author: Jeff Trost, MD


In your journal's May 1, 2012 article entitled "Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction," (1) Bradley et al report several strategies that are associated with significantly lower 30 day risk-standardized mortality rates (RSMR) for patients with acute myocardial infarction (AMI).

We were extremely surprised to learn that not crosstraining nurses from intensive care units (ICU) for the cardiac catheterization laboratory was associated with a reduction in RSMR. In fact, our institution's experience has been quite the opposite. In 2006, we began crosstraining ICU nurses in our cath lab, to create an after-hours "bridge" team with an in-house radiation technologist, to facilitate the transport and care of STEMI patients prior to primary percutaneous coronary intervention (PCI) while the on-call cath team traveled from home to hospital. As a result of this novel intervention, our median door-to-balloon time dropped over 30 minutes in a single year (note to Editor: could not import html table into content box) and has continued to decline, a performance improvement effort that has been acknowledged in a recent national quality improvement conference (QUEST 2010 National Conference, poster presentation) and that we hope to publish as a model for all STEMI programs. More importantly, we have seen a significant decline in mortality in all AMI patients (not just STEMI patients), which we believe is likely due to ICU nurses' familiarity with cath lab patients and post-PCI issues, as a result of their exposure to patients in the cath lab.

One is left to wonder if the question asked by the authors, "Were nurses in any of your critical care areas cross-trained to cover in the catheterization laboratory?" is actually flawed. Rather than a simple "yes" or "no" question, the answer for some hospitals may be "Yes" and "No." For example, there may be some hospitals who have ICU nurses crosstrained to help out in special circumstances like the care of STEMI patients (hence a "yes" answer), but these same hospitals also have a dedicated cath lab nursing staff both during working hours and on call (hence cath lab nursing is not exclusively comprised of ICU crosstrained nurses).

The authors attempt to explain the association between ICU crosstraining and increased RSMR as a result of "inadequate specialization in critical care nursing." Respectfully, we are not sure what this means. Every hospital has presepecified skills that an ICU nurse must meet before being credentialled in the ICU. Medical critical care nurses are trained to deal with the sickest individuals in the hospital, and patients with AMI certainly fit this bill, even with the best medical therapy. The authors also speculate that the increase of RSMR with ICU nurse crosstraining may be due to the "unintended effects of what might be a hospital cost-saving strategy." In our experience, crosstraining ICU nurses to be part of the bridge team involved a small amount of cost (related to ICU nurses training during separate hours from their ICU shifts) which was clearly worth the benefit of reducing DTB, STEMI mortality, and better care for all AMI patients.

Finally, the same authors previously identified five qualitative domains that distinguish top-performing hospital s from poor-performing hospitals with regard to RSMR. (2) Our decision to cross-train ICU nurses in the cath lab is based on the principles of several of these domains - communication and coordination among staff, a novel approach to both problem solving (reducing DTB) and learning (about cath lab patients), and ensuring broad staff presence and expertise. It would seem that this particular quantitative finding by the authors- that crosstraining ICU nurses in the cath lab leads to increased RSMR in AMI patients - runs completely counter to their qualitative findings. We certainly hope that their finding with respect to ICU nurse crosstraining does not discourage hospitals to discontinue this practice. In our experience, crosstraining ICU nurses in the cath lab has made an indelibly positive impact on the quality of care for AMI patients.


1. Bradley EH, Curry LA, Spatz ES, et al. Hospital Strategies for Reducing Risk-Standardized Mortality Rates for Acute Myocardial Infarction. Ann Intern Med. 2012;156:818-826.

2. Curry LA, Spatz E, Cherlin E, Thompson JW, Berg D, Ting HH et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med. 2011;154:384-90.

Conflict of Interest:

None declared

Author Response
Posted on June 15, 2012
Elizabeth Bradley, PhD, Leslie Curry, PhD, MPH, Erica S. Spatz, MD, MHS, Jeph Herrin, PhD†, Emily J. Cherlin, MSW, PhD*, Jeptha Curtis, MD, Jennifer W. Thompson, MPP, Henry H. Ting, MD, MBA, Yongfei Wang, MS, Harlan M. Krumholz, MD, SM
Section of Health Policy and Admin, Yale School of Public Health, New Haven, CT, Section of Cardiovascular Med, Dept of Med, Yale Univ School of Med, New Haven, CT, Div of Cardiovascular Diseases, Kn
Conflict of Interest: None Declared

Our research identified strategies that, on average were associated with lower 30-day risk-standardized mortality rates. The findings may differ at individual institutions depending on the context and implementation success of a particular strategy. Creating a bridge team, as noted in the letter by Trost and colleagues, is a different strategy than what we measured, which was cross-training of nurses from critical care areas for the cardiac catheterization laboratory. Although we are unable to empirically determine the underlying reason for this observed association, one possible explanation is inadequate team-building within the catheterization laboratory, as nurses may be substituted in regularly from other areas. The strategies we identified are complex interventions. Our results indicate that cross-training of nurses in critical care areas to cover the catheterization laboratory as currently implemented in most institutions is associated with worse performance. It is possible that, under certain circumstances, the effect of cross-training could be neutral or beneficial, but that is difficult to determine from the experience of a single institution.

This issue raised by Trost and colleagues highlights the importance of linking qualitative and quantitative data to understand not only individual strategies, such as cross-training nurses, but also contextual factors that may mitigate unintended effects of individual strategies, such as clinical engagement and cultural norms of interdisciplinary communication and collaboration, both highlighted in our earlier study (Curry et al, Annals, 2011). To the degree that cross-training nurses from critical care areas for bridge teams develops interdisciplinary communication and coordination across departments to care for patients with AMI, we agree that the strategy is likely to contribute to improved quality of care, and perhaps reductions in RSMR. At the same time, based on our findings (Bradley et al., Annals, 2012), merely cross-training nurses from critical care areas without such intentional coordination among groups may not be effective. Comprehensive evaluation of organizational strategies is important in order to identify best practices for broad dissemination.

Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.