Mortality rates for patients with acute myocardial infarction (AMI) vary substantially
across hospitals, even when adjusted for patient severity; however, little is known
about hospital factors that may influence this variation.
To identify factors that may be related to better performance in AMI care, as measured
by risk-standardized mortality rates.
Qualitative study that used site visits and in-depth interviews.
Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized
mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid
Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics.
158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals.
Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary
team performed analyses by using the constant comparative method.
Hospitals in the high-performing and low-performing groups differed substantially
in the domains of organizational values and goals, senior management involvement,
broad staff presence and expertise in AMI care, communication and coordination among
groups, and problem solving and learning. Participants described diverse protocols
or processes for AMI care (such as rapid response teams, clinical guidelines, use
of hospitalists, and medication reconciliation); however, these did not systematically
differentiate high-performing from low-performing hospitals.
The qualitative design informed the generation of hypotheses, and statistical associations
could not be assessed.
High-performing hospitals were characterized by an organizational culture that supported
efforts to improve AMI care across the hospital. Evidence-based protocols and processes,
although important, may not be sufficient for achieving high hospital performance
in care for patients with AMI.
Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth
Fund.