Randomized trial of targeted performance feedback to facilitate quality improvement in acute myocardial infarction care

Abstract

Background: Efforts to improve quality of care for patients with acute myocardial infarction (AMI) are a national priority. To date, there have been few studies that have prospectively evaluated hospital quality improvement (QI) interventions.

Methods and results: Using hospitals in the National Cardiovascular Data Registry (NCDR) ACTION Registry-GWTG, a cluster randomized trial of the effectiveness of targeted performance feedback to facilitate process improvement for AMI care will be conducted. ACTION Registry-GWTG hospitals with a minimum of 50 AMI patients per 2 quarters are eligible for randomization. The control arm receives standard performance feedback reports, and the intervention arm receives standard performance feedback reports in addition to a supplemental report on the "top 3" centrally identified, hospital-specific performance gaps. The primary outcome will be improvement in a composite of all metrics, and the secondary outcome will be improvement in the targeted metrics. At study inception in January 2009, 149 sites were randomized: 76 to the intervention arm, and 73 to the control arm. Intervention and control sites were well balanced in terms of baseline performance, center characteristics, and AMI volume (≈70 patients per quarter). The intervention phase will continue for 5 feedback cycles, each containing 2 quarters of data feedback over 18 months. A final trial outcome report will follow.

Conclusions: This randomized trial will evaluate a novel hospital-level QI intervention of targeted performance feedback for AMI, thereby demonstrating the effective use of national registries for QI and furthering our understanding of effective QI methods.

Trial registration: ClinicalTrials.gov NCT00952250.

Figure 1. Cluster randomized trial design

Eligible sites were randomized either to control or intervention and were stratified by baseline quality performance score, academic status, and cardiac services (hospitals with cardiac surgery vs. other).

Figure 2. CERTs NCDR ACTION Registry–GWTG report

Top page of report; but not shown are supplementary analysis data for each metric and patient level outlier reports.

Figure 3. Distribution of top three performance targets

The number of centers selected for each metric is shown by cluster (reperfusion, acute, discharge, dosing). Note: No centers selected for door-to-PCI among transfer patients or for door-to-needle.