Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction

Background: Despite recent improvements in survival after acute myocardial infarction (AMI), U. S. hospitals vary 2-fold in their 30-day risk-standardized mortality rates (RSMRs). Nevertheless, information is limited on hospital-level factors that may be associated with RSMRs. Objective: To identify hospital strategies that were associated with lower RSMRs. Design: Cross-sectional survey of 537 hospitals (91% response rate) and weighted multivariate regression by using data from the Centers for Medicare & Medicaid Services to determine the associations between hospital strategies and hospital RSMRs. Setting: Acute care hospitals with an annualized AMI volume of at least 25 patients. Participants: Patients hospitalized with AMI between 1 January 2008 and 31 December 2009. Measurements: Hospital performance improvement strategies, characteristics, and 30-day RSMRs. Results: In multivariate analysis, several hospital strategies were significantly associated with lower RSMRs and in aggregate were associated with clinically important differences in RSMRs. These strategies included holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital (RSMR lower by 0.70 percentage points), having cardiologists always on site (lower by 0.54 percentage points), fostering an organizational environment in which clinicians are encouraged to solve problems creatively (lower by 0.84 percentage points), not cross-training nurses from intensive care units for the cardiac catheterization laboratory (lower by 0.44 percentage points), and having physician and nurse champions rather than nurse champions alone (lower by 0.88 percentage points). Fewer than 10% of hospitals reported using at least 4 of these 5 strategies. Limitation: The cross-sectional design demonstrates statistical associations but cannot establish causal relationships. Conclusion: Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30-day RSMRs for patients with AMI.