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以改善护理的理解。目前的研究旨在扩大有关方法的信息匮乏，以增加可以提高护理质量的利用，特别是β受体阻滞剂的使用，这在全国各地的使用情况有明显的差异。我们的具体目标是：在为期三年的研究期间（1995- 1997年）确定与β受体阻滞剂使用变化相关的医院特征，并确定在研究期间与β受体阻滞剂使用显著增加相关的医院质量改进干预措施。急性心肌梗死（AMI）患者的β受体阻滞剂处方为研究提高护理质量的方法提供了一个理想的机会。在过去的二十年中，β受体阻滞剂已被证明可以降低AMI后幸存者的心血管发病率和死亡率。本研究的主要假设是，质量改善策略，而不是医院本身的特点，与出院时β受体阻滞剂使用的显著改善密切相关，即，改善的医院不会是特定的规模或类型。相反，我们假设显著的改善与全面的干预策略密切相关，该策略包括明确的机构对标准的认可（例如，关键途径，常设命令），绩效的监控和反馈，以及对负责变革的个人或团队的明确指定。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，以确定基于医院的干预措施，这些干预措施与AMI幸存者β受体阻滞剂使用的实质性改善有关。我们将补充来自全国心肌梗死登记处（National Registry of Myocardial Infarction）的数据，该登记处记录了1500多家医院的60多万例住院患者的详细信息，并对来自300家表现不同的医院的QI管理人员和医生进行了采访。该研究的后一部分将通过与Qualidigm（前身为康涅狄格州同行评审组织）的额外合作得到加强，该组织将指导从医院收集信息，并可以通过同行评审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.