Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: a randomized controlled trial

JAMA. 2003 Jul 2;290(1):49-56. doi: 10.1001/jama.290.1.49.


Context: A rigorous evaluation of continuous quality improvement (CQI) in medical practice has not been carried out on a national scale.

Objective: To test whether low-intensity CQI interventions can be used to speed the national adoption of 2 coronary artery bypass graft (CABG) surgery process-of-care measures: preoperative beta-blockade therapy and internal mammary artery (IMA) grafting in patients 75 years or older.

Design, setting, and participants: Three hundred fifty-nine academic and nonacademic hospitals (treating 267 917 patients using CABG surgery) participating in the Society of Thoracic Surgeons National Cardiac Database between January 2000 and July 2002 were randomized to a control arm or to 1 of 2 groups that used CQI interventions designed to increase use of the process-of-care measures.

Intervention: Each intervention group received measure-specific information, including a call to action to a physician leader; educational products; and periodic longitudinal, nationally benchmarked, site-specific feedback.

Main outcome measure: Differential incorporation of the targeted care processes into practice at the intervention sites vs the control sites, assessed by measuring preintervention (January-December 2000)/postintervention (January 2001-July 2002) site differences and by using a hierarchical patient-level analysis.

Results: From January 2000 to July 2002, use of both process measures increased nationally (beta-blockade, 60.0%-65.6%; IMA grafting, 76.2%-82.8%). Use of beta-blockade increased significantly more at beta-blockade intervention sites (7.3% [SD, 12.8%]) vs control sites (3.6% [SD, 11.5%]) in the preintervention/postintervention (P =.04) and hierarchical analyses (P<.001). Use of IMA grafting also tended to increase at IMA intervention sites (8.7% [SD, 17.5%]) vs control sites (5.4% [SD,15.8%]) (P =.20 and P =.11 for preintervention/postintervention and hierarchical analyses, respectively). Both interventions tended to have more impact at lower-volume CABG sites (for interaction: P =.04 for beta-blockade; P =.02 for IMA grafting).

Conclusions: A multifaceted, physician-led, low-intensity CQI effort can improve the adoption of care processes into national practice within the context of a medical specialty society infrastructure.

Publication types

  • Clinical Trial
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use*
  • Aged
  • Coronary Artery Bypass / standards*
  • Humans
  • Internal Mammary-Coronary Artery Anastomosis / statistics & numerical data*
  • Outcome and Process Assessment, Health Care
  • Premedication / statistics & numerical data*
  • Total Quality Management*
  • United States


  • Adrenergic beta-Antagonists