Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction

Med Care. 2005 Mar;43(3):282-92. doi: 10.1097/00005650-200503000-00011.


Background: Hospitals are under increasing pressure to measure and improve quality of care, and substantial resources are being directed at a variety of quality improvement strategies; however, the evidence base supporting these strategies is limited.

Objective: We sought to identify quality improvement efforts that were associated with hospitals' beta-blocker prescription rates after acute myocardial infarction (AMI).

Research design: This was a cross-sectional study using data from a telephone survey of quality management directors at participating hospitals linked with patient-level data from the National Registry of Myocardial Infarction (NRMI) during the study period, October 1997 to September 1999.

Subjects: A total of 60,363 patients discharged with a confirmed AMI from 234 US hospitals were included.

Measures: Hospital performance based on beta-blocker rates characterized as the top 20%, lower 20%, and middle 40% of hospitals; reported quality improvement efforts, including system interventions, physician leadership, administrative support for quality improvement efforts, and data feedback; hospital teaching status, AMI volume, geographic location, and ownership type.

Results: The mean hospital-specific beta-blocker rate was 60.2%; however, the variation in beta-blocker use across hospitals was marked (range, 19.4-89.3%, standard deviation, 12.7% points), and quality improvement efforts used varied greatly. None of the quality improvement efforts distinguished higher from medium performers; the higher and the medium performers together were distinguished from the lower performers in organizational support for quality improvement efforts (fully adjusted odds ratio [OR] 1.89, 95% confidence interval [CI] 1.17-3.06) and physician leadership (fully adjusted OR 9.88, 95% CI 2.64-37.02). Among the specific quality improvement interventions, only standing orders were associated with having higher/medium versus lower performance, and their effect had borderline significance (fully adjusted OR 2.26, 95% CI 0.97-5.30, P = 0.07).

Conclusions: Our findings highlight the organizational environment, specifically the absence of administrative support or physician leadership for quality improvement, as an important correlate of poor beta-blocker rates after AMI. Future studies are needed to isolate hospital quality improvement efforts that are associated with superior performance.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use*
  • Aged
  • Aged, 80 and over
  • Cross-Sectional Studies
  • Drug Utilization Review / statistics & numerical data*
  • Female
  • Hospitals / classification
  • Hospitals / standards*
  • Humans
  • Leadership
  • Male
  • Medical Staff, Hospital
  • Middle Aged
  • Myocardial Infarction / drug therapy*
  • Myocardial Infarction / prevention & control
  • Organizational Culture
  • Outcome Assessment, Health Care
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Quality Indicators, Health Care
  • Registries
  • Total Quality Management / organization & administration*
  • United States


  • Adrenergic beta-Antagonists