Although it is well documented that using beta blockers is effective in preventing a subsequent heart attack or death, not all hospitals are prescribing them widely for complicated internal reasons, a study by researchers at Yale concludes.
B-blockers slow the heart rate. The American Medical Association has reminded physicians of the importance of B-blocker use after an acute myocardial infarction (AMI) and both the Health Care Financing Administration and the National Committee for Quality Assurance have adopted B-blocker use after AMI as a quality-of-care indicator.
"Despite the evidence and the published guidelines, studies have repeatedly demonstrated wide variation and underuse of B-blockers," the Yale researchers said in a study published in the May 23 issue of the Journal of the American Medical Association. "Factors associated with successful improvement efforts to increase their use over time in the hospital setting are poorly understood."
To find out why, researchers at Yale conducted in-depth interviews in March-June 2000 with 45 key physician, nursing, quality management and administrative participants at eight U.S. hospitals chosen to represent a range of sizes, geographic regions, and changes in B-blocker use rates between October 1996 and September 1999.
The study was funded by the Agency for Healthcare Research and Quality. The goal was to develop a new way of classifying hospital-based quality improvement efforts and to provide insight into the features of successful efforts.
"While industry has made substantial advances in measuring and improving the quality of its products, these lessons are not easily translated into the complex healthcare environment," said Harlan Krumholz, M.D., senior author of the study and associate professor of internal medicine and cardiology at Yale School of Medicine. "Efforts to improve the quality of care in the health care system are increasingly common, but factors associated with successful initiatives are not well understood."
The researchers found six characteristics at hospitals where B-blockers were used frequently: goals for improvement; administrative support for improvement efforts; support among clinicians for such efforts; design and implementation of initiatives for performance improvement; use of data concerning B-blocker use, and a set of modifying variables.
"We found several important areas that distinguished efforts at these hospitals," said Elizabeth Bradley, first author and assistant professor in the Department of Epidemiology and Public Health. "The hospitals with the best performance were characterized by having clear support from their administration, strong physician leadership, a sense of shared goals and a way of monitoring their progress. These features were not generally present in the hospitals that did not perform as well."
The Yale researchers said the study is an important, though early, step in developing an evidence-based approach to improving the translation of research into practice.
"Many efforts are underway to improve quality of care in the hospital setting and ensure that all patients receive the very best care," Krumholz said. "Through this study and others, we are generating knowledge to guide those efforts."
Co-authors of the study included Eric Holmboe, M.D., Jennifer Mattera, Sarah Roumanis and Martha Radford, M.D.
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