Abstract & Commentary
Hospital Cultural and Organizational Characteristics Correlate with Important Mortality Differences in Managing Acute Myocardial Infarction
By David J. Pierson, MD, Editor, Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: This study of 537 hospitals found that those with the lowest mortality rates for acute myocardial infarction have management strategies that differ in important ways from those at hospitals with higher acute myocardial infarction mortality.
Source: Bradley EH, et al. Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction. Ann Intern Med 2012; 156:618-626.
Great strides have been made over the last couple of decades in the management of acute myocardial infarction (AMI), and widespread implementation of such interventions as aspirin, beta-blockers, and prompt reperfusion therapy has contributed to substantially reduced mortality from this leading killer. However, despite this progress, substantial differences persist with respect to AMI outcomes at different hospitals. Nationwide, the overall risk-standardized mortality rate (RSMR) within 30 days of AMI is around 15%. However, there is a 2-fold difference in RSMR between the best- and worst-performing hospitals. Bradley and colleagues at Yale sought to determine what characteristics of a hospital's organization and culture related to managing AMI might account for these differences.
In a study reported last year,1 these authors qualitatively identified strategies pertaining to top-performing hospitals' organizational values and goals; the involvement of their senior management; the expertise, communication, and coordination of their staff; and approaches to learning and problem solving that were prominent in their AMI care but not in their poor-performing counterparts. In this study, they surveyed a sample of hospitals reporting Centers for Medicare & Medicaid Services (CMS) data in order to test their earlier results more quantitatively. They randomly selected 600 hospitals from institutions reporting CMS data for RSMRs for AMI during the fiscal years 2005-2008, eliminating 10 hospitals that had since closed. They asked the CEO of each hospital to identify the person most involved in AMI quality improvement, and asked that individual to complete a Web-based survey based on the findings of the earlier study.
Of the 590 surveyed hospitals, 537 (91%) responded. One-third were teaching hospitals, slightly more than half had fewer than 300 beds, roughly half managed more than 125 AMI patients per year, and three-quarters performed percutaneous coronary intervention for ST-segment elevation AMI. Weighted mean AMI mortality in the surveyed hospitals was 15.4% (SD, 1.5%; range, 11.5% to 21.7%), with no significant differences from the non-surveyed hospitals in the CMS database.
The following hospital strategies were significantly associated with lower RSMRs in patients with AMI, with decrease in RSMR percentage points in parentheses:
- Holding monthly meetings to review AMI cases involving both hospital clinicians and the staff who transported the patients to the hospital (0.70);
- Having cardiologists onsite 24/7 (0.54);
- Fostering an organizational environment in which clinicians were encouraged to solve problems creatively (0.84); and
- Having both physician and nurse champions rather than nurse champions alone with respect to AMI care (0.88).
Another significant association was not staffing the cardiac catheterization laboratory with nurses cross-trained from the ICU (0.44). At least four of these five strategies were present in fewer than 10% of the hospitals in the study. Additional findings included significantly lower AMI mortality in hospitals that had pharmacists rounding on all patients with AMI (P < 0.025).
Commentary
In an era in which practice standards and the components of managing AMI are widely accepted and implemented, this study found important differences among hospitals correlating with RSMRs. These related to the organizational environment, including effective collaboration and communication among groups, broad staff presence and expertise, and a culture of problem solving and learning. Although the absolute effect sizes (for example, 0.54 to 0.88 percentage points) seem small, in the aggregate they exceeded an absolute difference of 1% in RSMR. Most importantly, considering the large numbers of patients with AMI managed nationally, eliminating the differences could make a difference of thousands of lives each year. As pointed out by the authors, the interventions involved — organizational and cultural rather than technological — carry little risk, and their implementation would not involve large amounts of new resources.
Most of the above findings suggest that high-performing and poor-performing hospitals with respect to AMI outcomes differ in their communication, collaboration, collegiality, and teamwork. Numerous studies in other aspects of critical care have shown that these characteristics are associated with better patient outcomes, and it is likely that the present study's findings have implications beyond the care of AMI.
Reference
- Curry LA, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med 2011;154:384-390.
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