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Context: During the last 2 decades, health care professional, consumer, and payer organizations have sought to improve outcomes for patients hospitalized with acute myocardial infarction (AMI). However, little has been reported about improvements in hospital short-term mortality rates or reductions in between-hospital variation in short-term mortality rates., Objective: To estimate hospital-level 30-day risk-standardized mortality rates (RSMRs) for patients discharged with AMI., Design, Setting, and Patients: Observational study using administrative data and a validated risk model to evaluate 3,195,672 discharges in 2,755,370 patients discharged from nonfederal acute care hospitals in the United States between January 1, 1995, and December 31, 2006. Patients were 65 years or older (mean, 78 years) and had at least a 12-month history of fee-for-service enrollment prior to the index hospitalization. Patients discharged alive within 1 day of an admission not against medical advice were excluded, because it is unlikely that these patients had sustained an AMI., Main Outcome Measure: Hospital-specific 30-day all-cause RSMR., Results: At the patient level, the odds of dying within 30 days of admission if treated at a hospital 1 SD above the national average relative to that if treated at a hospital 1 SD below the national average were 1.63 (95% CI, 1.60-1.65) in 1995 and 1.56 (95% CI, 1.53-1.60) in 2006. In terms of hospital-specific RSMRs, a decrease from 18.8% in 1995 to 15.8% in 2006 was observed (odds ratio, 0.76; 95% CI, 0.75-0.77). A reduction in between-hospital heterogeneity in the RSMRs was also observed: the coefficient of variation decreased from 11.2% in 1995 to 10.8%, the interquartile range from 2.8% to 2.1%, and the between-hospital variance from 4.4% to 2.9%., Conclusion: Between 1995 and 2006, the risk-standardized hospital mortality rate for Medicare patients discharged with AMI showed a significant decrease, as did between-hospital variation.

Objective: To evaluate the association between door-to-balloon time and mortality in hospital in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction to assess the incremental mortality benefit of reductions in door-to-balloon times of less than 90 minutes., Design: Prospective cohort study of patients enrolled in the American College of Cardiology National Cardiovascular Data Registry, 2005-6., Setting: Acute care hospitals., Participants: 43 801 patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention., Main Outcome Measure: Mortality in hospital., Results: Median door-to-balloon time was 83 minutes (interquartile range 6-109, 57.9% treated within 90 minutes). Overall mortality in hospital was 4.6%. Multivariable logistic regression models with fractional polynomial models indicated that longer door-to-balloon times were associated with a higher adjusted risk of mortality in hospital in a continuous non-linear fashion (30 minutes=3.0%, 60 minutes=3.5%, 90 minutes=4.3%, 120 minutes=5.6%, 150 minutes=7.0%, 180 minutes=8.4%, P<0.001). A reduction in door-to-balloon time from 90 minutes to 60 minutes was associated with 0.8% lower mortality, and a reduction from 60 minutes to 30 minutes with a 0.5% lower mortality., Conclusion: Any delay in primary percutaneous coronary intervention after a patient arrives at hospital is associated with higher mortality in hospital in those admitted with ST elevation myocardial infarction. Time to treatment should be as short as possible, even in centres currently providing primary percutaneous coronary intervention within 90 minutes.

Context: Allowing nonelectrophysiologists to perform implantable cardioverter-defibrillator (ICD) procedures is controversial. However, it is not known whether outcomes of ICD implantation vary by physician specialty., Objective: To determine the association of implanting physician certification with outcomes following ICD implantation., Design, Setting, and Patients: Retrospective cohort study using cases submitted to the ICD Registry performed between January 2006 and June 2007. Patients were grouped by the certification status of the implanting physician into mutually exclusive categories: electrophysiologists, nonelectrophysiologist cardiologists, thoracic surgeons, and other specialists. Hierarchical logistic regression models were developed to determine the independent association of physician certification with outcomes., Main Outcome Measures: In-hospital procedural complication rates and the proportion of patients meeting criteria for a defibrillator with cardiac resynchronization therapy (CRT-D) who received that device., Results: Of 111,293 ICD implantations included in the analysis, 78,857 (70.9%) were performed by electrophysiologists, 24,399 (21.9%) by nonelectrophysiologist cardiologists, 1862 (1.7%) by thoracic surgeons, and 6175 (5.5%) by other specialists. Compared with patients whose ICD was implanted by electrophysiologists, patients whose ICD was implanted by either nonelectrophysiologist cardiologists or thoracic surgeons were at increased risk of complications in both unadjusted (electrophysiologists, 3.5% [2743/78,857]; nonelectrophysiologist cardiologists, 4.0% [970/24,399]; thoracic surgeons, 5.8% [108/1862]; P < .001) and adjusted analyses (relative risk [RR] for nonelectrophysiologist cardiologists, 1.11 [95% confidence interval {CI}, 1.01-1.21]; RR for thoracic surgeons, 1.44 [95% CI, 1.15-1.79]). Among 35,841 patients who met criteria for CRT-D, those whose ICD was implanted by physicians other than electrophysiologists were significantly less likely to receive a CRT-D device compared with patients whose ICD was implanted by an electrophysiologist in both unadjusted (electrophysiologists, 83.1% [21 303/25,635]; nonelectrophysiologist cardiologists, 75.8% [5950/7849]; thoracic surgeons, 57.8% [269/465]; other specialists, 74.8% [1416/1892]; P < .001) and adjusted analyses (RR for nonelectrophysiologist cardiologists, 0.93 [95% CI, 0.91-0.95]; RR for thoracic surgeons, 0.81 [95% CI, 0.74-0.88]; RR for other specialists, 0.97 [95% CI, 0.94-0.99])., Conclusions: In this registry, nonelectrophysiologists implanted 29% of ICDs. Overall, implantations by a nonelectrophysiologist were associated with a higher risk of procedural complications and lower likelihood of receiving a CRT-D device when indicated compared with patients whose ICD was implanted by an electrophysiologist.

Cardiovascular imaging has enjoyed both rapid technological advances and sustained growth, yet less attention has been focused on quality than in other areas of cardiovascular medicine. To address this deficit, representatives from cardiovascular imaging societies, private payers, government agencies, the medical imaging industry, and experts in quality measurement met, and this report provides an overview of the discussions. A consensus definition of quality in imaging and a convergence of opinion on quality measures across imaging modalities was achieved and are intended to be the start of a process culminating in the development, dissemination, and adoption of quality measures for all cardiovascular imaging modalities.

Background: Patients and purchasers prefer board-certified physicians, but whether these physicians provide better quality of care and outcomes for hospitalized patients is unclear., Objective: We evaluated whether care by board-certified physicians after acute myocardial infarction (AMI) was associated with higher use of clinical guideline recommended therapies and lower 30-day mortality., Subjects and Methods: We examined 101,251 Medicare patients hospitalized for AMI in the United States and compared use of aspirin, beta-blockers, and 30-day mortality according to the attending physicians' board certification in family practice, internal medicine, or cardiology., Results: Board-certified family practitioners had slightly higher use of aspirin (admission: 51.1% vs 46.0%; discharge: 72.2% vs 63.9%) and beta-blockers (admission: 44.1% vs 37.1%; discharge: 46.2% vs 38.7%) than nonboard-certified family practitioners. There was a similar pattern in board-certified Internists for aspirin (admission: 53.7% vs 49.6%; discharge: 78.2% vs 68.8%) and beta-blockers (admission: 48.9% vs 44.1%; discharge: 51.2% vs 47.1). Board-certified cardiologists had higher use of aspirin compared with cardiologists certified in internal medicine only or without any board certification (admission: 61.3% vs 53.1% vs 52.1%; discharge: 82.2% vs 71.8% vs 71.5%) and beta-blockers (admission: 52.9% vs 49.6% vs 41.5%; discharge: 54.7% vs 50.6% vs 42.5%). In multivariate regression analyses, board certification was not associated with differences in 30-day mortality., Conclusions: Treatment by a board-certified physician was associated with modestly higher quality of care for AMI, but not differences in mortality. Regardless of board certification, all physicians had opportunities to improve quality of care for AMI.

Background: The association between low blood pressure and prognosis in the general population has been controversial, with some reports suggesting an increased mortality for patients with the lowest blood pressures. Whereas many standard heart failure therapies decrease blood pressure, the relationship between mortality and blood pressure in patients with heart failure has not been previously evaluated., Methods: We used the Digitalis Investigation Group trial database to evaluate retrospectively the relationship among systolic blood pressure (SBP), diastolic blood pressure (DBP), and survival among 5747 patients with New York Heart Association class II or III heart failure and left ventricular ejection fraction < or = 0.45. Cox proportional hazards models were used to identify covariates predictive of long-term mortality., Results: The adjusted all-cause mortality rate during the entire study period for patients in the lowest SBP group (< 100 mm Hg) was 50% and was significantly higher than that of the reference group of patients with SBP of 130 to 139 mm Hg, which had a mortality rate of 32% (hazard ratio 1.65, 95% CI 1.25-2.17, P < .001). The relationship between SBP and mortality was significant (P < .001) and nonlinear (P = .009). The relationship between DBP and mortality was significant (P < .001), with the highest mortality seen in patients with DBP < 60 mm Hg., Conclusions: In patients with systolic dysfunction (left ventricular ejection fraction < or = 0.45) and New York Heart Association classes II and III symptoms, lower SBPs and DBPs were associated with greater mortality.

Background: Previous studies have reported that myocardial infarction (MI) treatment in New England differs from that of other regions of the United States. We sought to determine whether regional differences in MI treatment were independent of regional differences in patient, hospital, or physician characteristics, and whether the New England region's practice pattern was associated with better outcomes than those of patients in other regions., Methods: We evaluated 167,180 patients aged > or =65 years who were hospitalized with MI between 1994 to 1996 to assess regional variations in quality of care. Patients were evaluated for the use of reperfusion therapy, aspirin, and beta-blockers on admission and 30-day mortality rate. Hierarchical logistic regression models were used to determine whether practice patterns specific to New England were independent of regional variations in patient, physician, hospital, or other geographic characteristics., Results: New England had the highest use of beta-blockers (72% vs 52% other regions, P <.001), and aspirin (80% vs 76% other regions, P <.001), a lower use of reperfusion therapy (61% vs 67% other regions, P <.001), and the lowest risk-standardized 30-day mortality rate (15% vs 19% other regions, P <.001). These differences persisted after adjusting for patient, physician, and hospital characteristics., Conclusions: Patients with MI in New England have higher rates of medical therapy use and lower 30-day mortality rates than patients in other US regions. This pattern is independent of patient or provider characteristics, suggesting other factors likely contribute to better short-term outcomes in New England.

Context: Health care "report cards" have attracted significant consumer interest, particularly publicly available Internet health care quality rating systems. However, the ability of these ratings to discriminate between hospitals is not known., Objective: To determine whether hospital ratings for acute myocardial infarction (AMI) mortality from a prominent Internet hospital rating system accurately discriminate between hospitals' performance based on process of care and outcomes., Design, Setting, and Patients: Data from the Cooperative Cardiovascular Project, a retrospective systematic medical record review of 141 914 Medicare fee-for-service beneficiaries 65 years or older hospitalized with AMI at 3363 US acute care hospitals during a 4- to 8-month period between January 1994 and February 1996 were compared with ratings obtained from HealthGrades.com (1-star: worse outcomes than predicted, 5-star: better outcomes than predicted) based on 1994-1997 Medicare data., Main Outcome Measures: Quality indicators of AMI care, including use of acute reperfusion therapy, aspirin, beta-blockers, angiotensin-converting enzyme inhibitors; 30-day mortality., Results: Patients treated at higher-rated hospitals were significantly more likely to receive aspirin (admission: 75.4% 5-star vs 66.4% 1-star, P for trend =.001; discharge: 79.7% 5-star vs 68.0% 1-star, P =.001) and beta-blockers (admission: 54.8% 5-star vs 35.7% 1-star, P =.001; discharge: 63.3% 5-star vs 52.1% 1-star, P =.001), but not angiotensin-converting enzyme inhibitors (59.6% 5-star vs 57.4% 1-star, P =.40). Acute reperfusion therapy rates were highest for patients treated at 2-star hospitals (60.6%) and lowest for 5-star hospitals (53.6% 5-star, P =.008). Risk-standardized 30-day mortality rates were lower for patients treated at higher-rated than lower-rated hospitals (21.9% 1-star vs 15.9% 5-star, P =.001). However, there was marked heterogeneity within rating groups and substantial overlap of individual hospitals across rating strata for mortality and process of care; only 3.1% of comparisons between 1-star and 5-star hospitals had statistically lower risk-standardized 30-day mortality rates in 5-star hospitals. Similar findings were observed in comparisons of 30-day mortality rates between individual hospitals in all other rating groups and when comparisons were restricted to hospitals with a minimum of 30 cases during the study period., Conclusion: Hospital ratings published by a prominent Internet health care quality rating system identified groups of hospitals that, in the aggregate, differed in their quality of care and outcomes. However, the ratings poorly discriminated between any 2 individual hospitals' process of care or mortality rates during the study period. Limitations in discrimination may undermine the value of health care quality ratings for patients or payers and may lead to misperceptions of hospitals' performance.