IMPROVING THE QUALITY OF CARE FOR MEDICARE PATIENTS WITH ACUTE MYOCARDIAL-INFARCTION - RESULTS FROM THE COOPERATIVE CARDIOVASCULAR PROJECT

Context.-Medicare has a legislative mandate for quality assurance, but the effectiveness of its population-based quality improvement program s has been difficult to establish. Objective.-To improve the quality o f care for Medicare patients with acute myocardial infarction. Design. -Quality improvement project with baseline measurement, feedback, reme asurement, and comparison samples. Setting.-All acute care hospitals i n the United States. Patients.-Preintervention and postintervention sa mples included all Medicare patients in Alabama, Connecticut, Iowa, an d Wisconsin discharged with principal diagnoses of acute myocardial in farctions during 2 periods, June 1992 through December 1992 and August 1995 through November 1995, Indicator comparisons were made with a ra ndom sample of Medicare patients in the rest of the nation discharged with acute myocardial infarctions from August 1995 through November 19 95, Mortality comparisons involved all Medicare patients nationwide wi th inpatient claims for acute myocardial infarctions during 2 periods, June 1992 through May 1993 and August 1995 through July 1996. Interve ntion.-Data feedback by peer review organizations. Main Outcome Measur es.-Quality indicators derived from clinical practice guidelines, leng th of stay, and mortality. Results.-Performance on all quality indicat ors improved significantly in the 4 pilot states. Administration of as pirin during hospitalization in patients without contraindications imp roved from 84% to 90% (P<.001), and prescription of beta-blockers at d ischarge improved from 47% to 68% (P<.001), Mortality at 30 days decre ased from 18.9% to 17.1% (P=.005) and at 1 year from 32.3% to 29.6% (P <.001). These improvements in quality occurred during a period when me dian length of stay decreased from 8 days to 6 days. Performance on al l quality indicators except reperfusion was better in the pilot states than in the rest of the nation in 1995, and the differences were stat istically significant for aspirin use at discharge (P<.001), beta-bloc ker use (P<.001), and smoking cessation counseling (P=.02), Postinfarc tion mortality was not significantly different between the pilot state s and the rest of the nation during the baseline period, although it w as slightly but significantly better in the pilot states during the fo llow-up period (absolute mortality difference at 1 year, 0.9%, P=.004) . Conclusions.-The quality of care for Medicare patients with acute my ocardial infarction has improved in the Cooperative Cardiovascular Pro ject pilot states. Performance on the defined quality indicators appea red to be better in the pilot states than in the rest of the nation in 1995 and was associated with reduced mortality.