Can performance feedback encourage hospitals to improve heart attack treatment for Medicare beneficiaries?

Medical treatment of heart attack improved after Medicare peer review organizations in four states provided performance feedback to physicians and encouraged them to make practice improvements, which may have contributed to improved patient survival.

Why is this important?

Certain medications—aspirin, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors, when indicated—significantly reduce the recurrence of heart attack and improve patients' survival when prescribed during hospitalization and afterward as long-term preventive therapy for heart attack victims. Although the study illustrated here occurred in the 1990s, many patients still do not get these medications (see the Snapshot on Heart Attack Treatment in the Hospital). Thus there is still opportunity to learn from this example of improvement.

Interventions

The federal government initiated a Cooperative Cardiovascular Project and collaborated with the American Medical Association to develop quality indicators for heart attack treatment based on recognized clinical practice guidelines. Medicare Quality Improvement Organizations (QIOs), formerly called Peer Review Organizations (PROs), used these measures to collect and disseminate performance data to hospitals in four states. Feedback was provided through onsite presentations, regional seminars, telephone conferences, and mailings (Marciniak et al. 1998a).

QIOs collaborated with local professional associations to encourage improvements in medical treatment of heart attacks. Most hospitals submitted responses describing plans for quality improvement, such as creating or revising standing orders and critical pathways, or providing education and disseminating performance data.

Findings

Among Medicare patients who were ideal candidates for drug therapy:

• Aspirin use increased by 7 percentage points during hospitalization and by 10 percentage points at hospital discharge (aspirin helps prevent dangerous blood clots from forming).
• Beta-blocker and ACE inhibitor prescriptions at discharge increased by 20 percentage points and 14 percentage points, respectively (beta-blockers help the heart work better by decreasing its need for blood and oxygen; ACE inhibitors lower blood pressure and increase the supply of blood and oxygen to the heart).
• There was a 10 percent relative reduction in death rates measured at 30 days and one year after hospitalization, to a level slightly better than the rest of the nation (Marciniak et al. 1998a).

Implications

Sharing performance data and encouraging the adoption of specific improvement plans can help promote widespread improvement in quality-of-care and health outcomes (Marciniak et al. 1998b). Exemplary hospitals noted the importance of forming interdisciplinary teams and identifying a physician leader to champion quality improvement with peers (CCP 1998).

This project and the indicators it developed served as a precursor to common adoption of these and similar quality measures leading to public reporting of hospital performance through the recent Hospital Quality Alliance initiative.

In a recent review, the Institute of Medicine concluded that "the existing evidence is inadequate to determine the extent to which the QIO program has contributed to [quality] improvements" in Medicare. Nevertheless, the committee characterized the QIO program as "a potentially valuable nationwide infrastructure dedicated to promoting quality health care" and recommended that the program be strengthened as a means of providing "technical assistance in support of quality improvement" (IOM 2006).

Improvement Ideas and Resources

Additional resources are available from the Medicare Quality Improvement Community.

Measure:

This before-and-after study used a pre-intervention sample of 13,946 hospital discharges from June 1992 through December 1992, and a post-intervention sample of 8,163 hospital discharges from August 1995 through November 1995, for Medicare patients with a principal diagnosis of acute myocardial infarction in Alabama, Connecticut, Iowa, and Wisconsin. Mortality comparisons used hospital claims for all Medicare patients nationwide. There was no statistically significant difference in mortality rates between intervention states and the rest of the nation at baseline, while intervention states had a slightly but statistically significant lower rate post-intervention (Marciniak et al. 1998a).

Limitations:

The study was not a controlled trial. Other factors and initiatives may have contributed to improved results in the study states.

Source:

The Medicare Cooperative Cardiovascular Project pilot was conducted by the federal government in collaboration with state Medicare peer review organizations (PROs). Data were abstracted from hospital medical records (Marciniak et al. 1998a).

References:

* Indicates source of data used in the chart(s).CCP (Cooperative Cardiovascular Project Best Practices Working Group). 1998. Improving Care for Acute Myocardial Infarction: Experience from the Cooperative Cardiovascular Project. The Joint Commission Journal on Quality Improvement 24(9): 480–90.

IOM (Institute of Medicine). 2006. Medicare's Quality Improvement Organization Program: Maximizing Potential. Washington, D.C.: National Academy Press.

* Marciniak, T. A., E. F. Ellerbeck, M. J. Radford et al. 1998a. Improving the Quality of Care for Medicare Patients with Acute Myocardial Infarction: Results from the Cooperative Cardiovascular Project. Journal of the American Medical Association 279 (17): 1351–7.

Marciniak, T. A., L. Mosedale, and E. F. Ellerbeck. 1998b. Quality Improvement at the National Level. Lessons from the Cooperative Cardiovascular Project. Evaluation & The Health Professions 21 (4): 525–36.