HOSPITAL PERFORMANCE & BETA-BLOCKER USE AFTER AMI

拟议研究的广泛目标是增加我们对以医院为基础的干预措施的了解，以改善护理。目前的研究旨在扩大关于提高利用率以提高护理质量的方法的信息匮乏，特别是β-受体阻滞剂的使用，这种药物在全国各地的使用情况有显著差异。我们的具体目标将是：确定在三年研究期间(1995-2007年)与β-受体阻滞剂使用变化有关的医院特征，并确定与研究期间β-受体阻滞剂使用显著增加有关的以医院为基础的质量改进干预措施。为急性心肌梗死(AMI)患者开出β-受体阻滞剂的处方是研究提高护理质量的方法的理想机会。在过去的二十年里，β-受体阻滞剂已经被证明可以降低急性心肌梗死后幸存者的心血管发病率和死亡率。这项研究的主要假设是，质量改进策略，而不是医院本身，与出院时β-受体阻滞剂使用的显著改善密切相关，即改善的医院将不是特定规模或类型。相反，我们假设，显著的改善与全面的干预战略密切相关，该战略包括明确的机构认可标准(例如，关键路径、常规命令)、对业绩的监测和反馈以及明确指定负责变革的人员或团队。为了实现我们的目标，我们提出了一项回顾性队列研究和嵌套病例对照研究，以确定与显著改善急性心肌梗死幸存者使用β-受体阻滞剂相关的医院干预措施。我们将补充来自全国心肌梗死登记处的数据，这是一个全国性的详细患者信息登记处，在1500多家医院有60多万次住院治疗，来自300家表现不同水平的医院的QI经理和医生的访谈信息。这项研究的后半部分将通过Qualidigm(前身为康涅狄格州同行审查组织)的额外合作伙伴关系得到加强，该伙伴关系将指导从医院收集信息，并可通过同行审查法规为数据提供保密。

The broad objective of the proposed study is to increase our understanding of hospital-based interventions to improve care. The current research is aimed at expanding the paucity of information about methods to increase the utilization that can improve the quality of care, and, particularly, the use of beta- blockers, which have marked variation in usage across the country. Our specific aims will be: to identify the hospital characteristics associated with the change in the use of beta-blockers over a three-year study period (1995-7) and to identify the hospital-based quality improvement interventions that are associated with a marked increase in the use of beta-blockers during the study period. The prescription of beta-blockers for patients after an acute myocardial infarction (AMI) represents an ideal opportunity to study methods of improving quality of care. During the last two decades, beta-blockers have been shown to reduce cardiovascular morbidity and mortality for survivors after AMI. The primary hypothesis of this study is that quality improvement strategies, not hospital characteristics themselves, are strongly associated with marked improvement in the use of beta-blockers at discharge, i.e., the hospitals that improve will not be a specific size or type. Instead, we hypothesize that marked improvement is most strongly associated with a comprehensive intervention strategy that includes the combination of explicit institutional endorsement of standards (e.g., critical pathways, standing orders), the monitoring and feedback of performance, and the clear designation of persons or teams with responsibility for change. To accomplish our aims, we propose a retrospective cohort study and nested case-control to identify hospital-based interventions that are associated with substantial improvements in the use of beta-blockers for survivors of an AMI. We will supplement data from the National Registry of Myocardial Infarction, a national registry of detailed patient information that has more than 600,000 hospitalizations in more than 1,500 hospitals, with information from interviews of QI managers and physicians at 300 hospitals with varying levels of performance. This latter part of the study will be enhanced through the additional partnership of Qualidigm (formerly the Connecticut Peer Review Organization) which will direct the collection of information from the hospitals, and which can provide, through Peer Review statutes, confidentiality for the data.