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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)., Research Design: 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., Subjects: A total of 60,363 patients discharged with a confirmed AMI from 234 US hospitals were included., Measures: 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.

Background: National surveys indicate improvement in beta-blocker use after acute myocardial infarction (AMI) over time; however, these data could obscure important variation in improvement at individual hospitals. Our objective was to characterize the hospital-level variation in the improvements in beta-blocker prescription rates after AMI and to identify hospital characteristics that were associated with hospital improvement rates after adjustment for patient demographic and clinical characteristics., Methods and Results: We used data (n = 335,244 patients with AMI discharged from 682 hospitals) from the National Registry of Myocardial Infarction (NRMI) and from the American Hospital Association Annual Survey of Hospitals and hierarchical modeling to examine the associations between hospital characteristics and hospital-level rates of change in beta-blocker use during 1996-1999. On average, hospital rates of beta-blocker use for patients with AMI increased 5.9 percentage points (standard deviation, 9.7 percentage points) from the premidpoint time period (April 1996-February 1998) to the postmidpoint time period (March 1998-September 1999) of the study. The range in hospital-level changes in beta-blocker rates was substantial, from a decline of -50.0 percentage points to an increase of +35.7 percentage points. AMI volume and teaching status, geographic region, and initial beta-blocker use rates were associated with rate of improvement, but the magnitude of these effects was modest., Conclusions: The study reveals marked hospital-level variation in improvement in beta-blocker use after AMI. Several hospital characteristics were associated with this improvement, but they are weak predictors of hospital-based improvement in the use of beta-blockers.

Objectives: To examine whether physical and cognitive impairments explain low use of beta-blockers in elderly patients and whether functionally impaired older adults have improved survival if a beta-blocker is prescribed at hospital discharge., Design: Cross-sectional and retrospective cohort study., Setting: Acute care hospitals in the United States., Participants: National cohort of 45,370 elderly acute myocardial infarction survivors, with no chart-documented contraindications to beta-blocker treatment., Measurements: The main outcome measures were beta-blocker prescription at hospital discharge and 1-year survival., Results: Fifty percent (n=22,683) of eligible patients were prescribed a beta-blocker at discharge. Older age and functional impairments (incontinence, mobility impairment, and cognitive impairment) were independently associated with decreased use of beta-blockers. The odds ratios for prescribing a beta-blocker at hospital discharge were 0.82 (95% confidence interval (CI)=0.77-0.86), 0.63 (95% CI=0.56-0.71), and 0.40 (95% CI=0.32-0.51) for persons with one, two, and three impairments, respectively, compared with those with no impairments. In survival analysis, patients prescribed a beta-blocker were 21% less likely than nonrecipients to die within 1 year of follow-up (relative risk=0.79, P=.0001). Similar survival benefit was observed in patients with and without functional impairments., Conclusion: This study shows a strong association between functional impairment and the use of beta-blockers after acute myocardial infarction in elderly patients. The results suggest that increasing use of beta-blockers in this group provides an opportunity to improve outcomes.

Background: Despite the many proposed methods for improving quality, little is known about which methods are being applied in practice across the United States or their perceived effectiveness., Methods: A descriptive, cross-sectional analysis of data from a telephone survey of quality improvement staff in 234 randomly selected hospitals participating in the National Registry of Myocardial Infarction was conducted to examine the prevalence and perceived effectiveness of various quality improvement interventions directed at increasing beta-blocker use after acute myocardial infarction., Results: The mean and median number of quality improvement interventions directed at beta-blocker use in the past 4 years was 5.0 per hospital. The most commonly reported effort was performance reporting about beta-blocker use (87.9%), although only 26.7% used physician-specific performance reporting. More than half the hospitals implemented clinical pathways (58.1%), standing orders (56.8%), or care coordinators (50.4%). Care coordinators (63.4%) and computer support systems (61.6%) were most frequently rated as "very effective." Clinical pathways (24.2%), counseling physicians who had poor performance (26.9%), and reminder forms (23.0%) were most frequently rated as not effective., Conclusions: Substantial variation in the types of quality improvement efforts implemented to increase beta-blocker use and perceived effectiveness were evident.

Background: The influence of physician leaders on their colleagues in local medical communities has been recognized for several decades. However, the literature indicates that little is known about the specific characteristics of physician leaders involved in improving quality in today's hospital environment. A taxonomy of the characteristics of the physician quality leader from the perspective of physicians and nonphysicians was developed., Subjects and Methods: Information about physician leaders working to improve acute myocardial infarction (AMI) was gathered from in-depth interviews with 45 key physicians and nursing, quality management, and administrative staff at eight hospitals. Data were analyzed using the constant comparative method of qualitative data analysis., Results: The physician leader characteristics were described in four main categories: personal commitment, professional credibility, quality improvement behaviors and skills, and institutional linkages. Each physician leader possessed different combinations of the characteristics from the four categories, revealing the complexity of the physician leader role., Conclusion: Understanding the key characteristics of physician leaders is a critical step in helping hospitals choose and develop physician leaders who can effectively bring about meaningful quality improvement.

Purpose: Older patients are less likely to receive guideline-recommended medical therapies during acute myocardial infarction. However, it is unclear whether the lower rates of treatment reflect elderly patients' increased number of comorbid conditions, physician or hospital effects, or true age-associated variation. Furthermore, it is unclear whether age-associated variations in care are similar or vary among treatments., Methods: We evaluated 146,718 Medicare patients from the Cooperative Cardiovascular Project aged > or =65 years who were hospitalized between 1994 and 1996 with a confirmed myocardial infarction, to ascertain whether rates of acute reperfusion therapy and use of aspirin (admission, discharge), beta-blockers (admission, discharge), and angiotensin-converting enzyme (ACE) inhibitors varied among patients aged 65 to 69 years, 70 to 74 years, 75 to 79 years, 80 to 84 years, and > or =85 years. We identified patients who were considered eligible for each therapy and who had no treatment contraindications. Associations between age and use of therapy were assessed, adjusting for patient, physician, hospital, and geographic factors., Results: Adjusted treatment rates were higher for patients aged 65 to 69 years than for patients aged > or =85 years for acute reperfusion therapy (54.4% vs. 31.2%, P <0.0001 for trend), beta-blockers (admission: 52.2% vs. 43.8%, P <0.0001 for trend; discharge: 61.8% vs. 55.3%, P <0.0001 for trend), aspirin at admission (73.8% vs. 71.0%, P <0.0001 for trend), and ACE inhibitors (61.6% vs. 57.1%, P = 0.02 for trend); there were no differences in the prescription of aspirin at discharge (76.0% vs. 73.6%, P = 0.05)., Conclusion: Elderly patients are less likely to receive guideline-indicated therapies when hospitalized with myocardial infarction. The effects of age were largest for acute reperfusion and smallest for aspirin.

Objectives: We evaluated the use and effectiveness of beta-blocker therapy after acute myocardial infarction (AMI) for elderly patients with chronic obstructive pulmonary disease (COPD) or asthma., Background: Because patients with COPD and asthma have largely been excluded from clinical trials of beta-blocker therapy for AMI, the extent to which these patients would benefit from beta-blocker therapy after AMI is not well defined., Methods: Using data from the Cooperative Cardiovascular Project, we examined the relationship between discharge use of beta-blockers and one-year mortality in patients with COPD or asthma who were not using beta-agonists, patients with COPD or asthma who were concurrently using beta-agonists and patients with evidence of severe disease (use of prednisone or previous hospitalization for COPD or asthma) compared with patients without COPD or asthma., Results: Of 54,962 patients without contraindications to beta-blockers, patients with COPD or asthma (20%) were significantly less likely to be prescribed beta-blockers at discharge after AMI. After adjusting for demographic and clinical factors, we found that beta-blockers were associated with lower one-year mortality in patients with COPD or asthma who were not on beta-agonist therapy (relative risk [RR] = 0.85, 95% confidence interval [CI] 0.73 to 1.00), similar to patients without COPD or asthma (RR = 0.86, 95% CI 0.81 to 0.92). A survival benefit for beta-blockers was not found among patients concurrently using beta-agonists or with severe COPD or asthma., Conclusions: Beta-blocker therapy after AMI may be beneficial for COPD or asthma patients with mild disease. A survival benefit was not found for elderly AMI patients with more severe pulmonary disease.

Context: Based on evidence that beta-blockers can reduce mortality in patients with acute myocardial infarction (AMI), many hospitals have initiated performance improvement efforts to increase prescription of beta-blockers at discharge. Determination of the factors associated with such improvements may provide guidance to hospitals that have been less successful in increasing beta-blocker use., Objectives: To identify factors that may influence the success of improvement efforts to increase beta-blocker use after AMI and to develop a taxonomy for classifying such efforts., Design, Setting, and Participants: Qualitative study in which data were gathered from in-depth interviews conducted in March-June 2000 with 45 key physician, nursing, quality management, and administrative participants at 8 US hospitals chosen to represent a range of hospital sizes, geographic regions, and changes in beta-blocker use rates between October 1996 and September 1999., Main Outcome Measures: Initiatives, strategies, and approaches to improve care for patients with AMI., Results: The interviews revealed 6 broad factors that characterized hospital-based improvement efforts: goals of the efforts, administrative support, support among clinicians, design and implementation of improvement initiatives, use of data, and modifying variables. Hospitals with greater improvements in beta-blocker use over time demonstrated 4 characteristics not found in hospitals with less or no improvement: shared goals for improvement, substantial administrative support, strong physician leadership advocating beta-blocker use, and use of credible data feedback., Conclusions: This study provides a context for understanding efforts to improve care in the hospital setting by describing a taxonomy for classifying and evaluating such efforts. In addition, the study suggests possible elements of successful efforts to increase beta-blocker use for patients with AMI.

Background: Although randomized clinical trials have demonstrated that beta-blocker therapy is effective in reducing mortality after acute myocardial infarction (AMI), many of these studies excluded patients who undergo coronary revascularization. However, the clinical practice guidelines established by the American College of Cardiology and the American Heart Association recommend that beta-blocker therapy be considered for patients who underwent successful revascularization after AMI., Methods: Using data from the Cooperative Cardiovascular Project, we compared the initiation of beta-blocker therapy at discharge in patients aged 65 years or older who underwent coronary artery bypass surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) during their hospitalization for AMI with that of patients who did not undergo revascularization. We then examined whether beta-blocker therapy was associated with lower 1-year mortality between revascularized and nonrevascularized groups., Results: After excluding patients with contraindications to beta-blocker therapy, 84 457 patients remained in the study sample. Of these, 8482 patients underwent CABG, and 13 997 patients underwent PTCA. After adjusting for demographic and clinical factors, we found that these patients were less likely to initiate beta-blocker therapy after CABG (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.41-0.47) or PTCA (OR, 0.89; 95% CI, 0.85-0.93) relative to the nonrevascularized group. After adjusting for potential confounders, beta-blockers were significantly associated with lower 1-year mortality in patients who underwent CABG (hazard ratio [HR], 0.70; 95% CI, 0.55-0.89) or PTCA (HR, 0.86; 95% CI, 0.74-1.00), similar to that of the non-revascularized group (HR, 0.83; 95% CI, 0.80-0.87)., Conclusions: Therapy after AMI with beta-blockers appears to be as effective in reducing 1-year mortality for elderly patients who have undergone CABG or PTCA as for a nonrevascularized group. Our findings suggest that routine use of beta-blockers should be considered for patients who undergo revascularization after AMI.

Background: Despite the evidence supporting the importance of early beta-blocker therapy, this intervention has received little attention as an indicator of quality of care., Objectives: To determine how often beta-blockers are administered as early treatment of acute myocardial infarction in patients 65 years of age or older, to identify predictors of the decision to use beta-blockers, and to evaluate the association between the early use of beta-blockers and in-hospital mortality., Design: Observational study., Setting: Nongovernment, acute care hospitals in the United States., Patients: Medicare beneficiaries who were 65 years of age or older, were hospitalized with an acute myocardial infarction in 1994 and 1995, and did not have a contraindication to beta-blocker therapy., Measurements: Medical chart review to obtain information about the use of beta-blockers, contraindications to these drugs, patient demographics, and clinical factors., Results: Of the 58 165 patients (from a total of 4414 hospitals), 28 256 (49%) received early beta-blocker therapy. Patients with the highest risk for in-hospital death were the least likely to receive therapy. Patients who received beta-blockers had a lower in-hospital mortality rate than patients who did not receive beta-blockers (odds ratio, 0.81 [95% CI, 0.75 to 0.87]), even after adjustment for baseline differences in demographic, clinical, and treatment characteristics between the two groups., Conclusions: Early beta-blocker therapy was not used for 51% of elderly patients who were hospitalized with an acute myocardial infarction and did not have a contraindication to this therapy. Increasing the early use of beta-blockers for these patients would provide an excellent opportunity to improve their care and outcomes.

Objectives: We sought to determine the use and association with one-year mortality of beta-blocker therapy for the treatment of acute myocardial infarction (AMI) in elderly diabetic patients and to examine whether beta-blocker therapy was associated with increased rates of hospital readmission for diabetic complications traditionally associated with beta-blockers., Background: Although many randomized trials have demonstrated that beta-blockers are effective in reducing mortality after AMI, some experts are concerned about the use of beta-blockers in diabetic patients. Little is known about the effectiveness and complication rate of beta-blocker therapy after AMI for elderly diabetics in community practice settings., Methods: We conducted a retrospective cohort study using the National Cooperative Cardiovascular Project, which contained data abstracted from hospital medical records of Medicare beneficiaries admitted with an AMI during 1994 and 1995., Results: Out of 45,308 patients without contraindications to beta-blocker therapy, 7.4% were insulin-treated diabetics and 18.5% were non-insulin-treated diabetics. Beta-blockers were prescribed at discharge for 45% of insulin-treated diabetics, 48.1% of non-insulin-treated diabetics and 51% of nondiabetics (p < 0.001). After adjusting for demographic and clinical factors, diabetics continued to be less likely to receive beta-blockers at discharge compared with nondiabetics (odds ratio [OR] for insulin-treated diabetics 0.88, 95% confidence interval [CI] 0.82 to 0.96; OR for non-insulin-treated diabetics 0.93, 95% CI 0.88 to 0.98). After adjusting for potential confounders, beta-blockers were associated with lower one-year mortality for insulin-treated diabetics (hazard ratio [HR] = 0.87, 95% CI 0.72 to 1.07), non-insulin-treated diabetics (HR = 0.77, 95% CI 0.67 to 0.88) and nondiabetics (HR = 0.87, 95% CI 0.80 to 0.94). Beta-blocker therapy was not significantly associated with increased six-month readmission rates for diabetic complications among diabetics and nondiabetics., Conclusions: Beta-blockers are associated with a lower one-year mortality rate for elderly diabetic patients to a similar extent as for nondiabetics, without increased risk of readmission for diabetic complications. Increasing the use of beta-blockers in elderly diabetic patients represents an opportunity to improve the care and outcomes of these patients after AMI.

Context: Despite the importance of beta-blockers for secondary prevention after acute myocardial infarction (AMI), several studies have suggested that they are substantially underutilized, particularly in older patients., Objectives: To describe the contemporary national pattern of beta-blocker prescription at hospital discharge among patients aged 65 years or older with an AMI, to identify the most important predictors of the prescribed use of beta-blockers at discharge, and to determine the independent association between beta-blockers at discharge and mortality in clinical practice., Design: Retrospective cohort study using data created from medical charts and administrative files., Setting: Acute care nongovernmental hospitals in the United States., Patients: National cohort of 115015 eligible patients aged 65 years or older who survived hospitalization with a confirmed AMI in 1994 or 1995., Main Outcome Measures: Blocker as a discharge medication and mortality in the year after discharge., Results: Among the 45308 patients without contraindications to beta-blockers, 22665 (50.0%) had a beta-blocker as a discharge medication. There was significant variation by state, ranging from 30.3% to 77.1 %. Of the 36795 patients who were not receiving beta-blocker therapy on admission, 16006 (43.5%) had therapy initiated on or before discharge. Demographic and clinical variables explained relatively little of the variation in the initiation of beta-blocker therapy. The prescribed use of calcium channel blockers at discharge had a strong negative association with the use of beta-blockers (odds ratio [OR] of beta-blocker use, 0.25; 95% confidence interval [CI], 0.24-0.26). The New England region had significantly higher use of beta-blocker therapy than the rest of the country. Compared with cardiologists, internists had similar rates (OR, 0.94; 95% CI, 0.90-1.00) and general and family practice physicians had lower rates (OR, 0.78; 95% CI, 0.73-0.83). After adjusting for potential confounders, beta-blockers were associated with a 14% lower risk of mortality at 1 year after discharge. The association with lower mortality was present in subgroups stratified by age, sex, and left ventricular ejection fraction., Conclusions: Many ideal patients for beta-blocker therapy are not prescribed these drugs at discharge following AMI. The clinical and demographic characteristics of the patients do not explain much of the variation in the treatment pattern. Geographic factors and physician specialty are independently associated with the decision to use beta-blockers. Elderly patients who are prescribed beta-blockers at discharge have a better survival rate, consistent with the findings of randomized controlled trials of younger and lower-risk populations.