A rigorous evaluation of continuous quality improvement (CQI) in medical
practice has not been carried out on a national scale.
To test whether low-intensity CQI interventions can be used to speed
the national adoption of 2 coronary artery bypass graft (CABG) surgery process-of-care
measures: preoperative β-blockade therapy and internal mammary artery
(IMA) grafting in patients 75 years or older.
Design, Setting, and Participants
Three hundred fifty-nine academic and nonacademic hospitals (treating
267 917 patients using CABG surgery) participating in the Society of
Thoracic Surgeons National Cardiac Database between January 2000 and July
2002 were randomized to a control arm or to 1 of 2 groups that used CQI interventions
designed to increase use of the process-of-care measures.
Each intervention group received measure-specific information, including
a call to action to a physician leader; educational products; and periodic
longitudinal, nationally benchmarked, site-specific feedback.
Main Outcome Measure
Differential incorporation of the targeted care processes into practice
at the intervention sites vs the control sites, assessed by measuring preintervention
(January-December 2000)/postintervention (January 2001-July 2002) site differences
and by using a hierarchical patient-level analysis.
From January 2000 to July 2002, use of both process measures increased
nationally (β-blockade, 60.0%-65.6%; IMA grafting, 76.2%-82.8%). Use
of β-blockade increased significantly more at β-blockade intervention
sites (7.3% [SD, 12.8%]) vs control sites (3.6% [SD, 11.5%]) in the preintervention/postintervention
(P = .04) and hierarchical analyses (P<.001). Use of IMA grafting also tended to increase at IMA intervention
sites (8.7% [SD, 17.5%]) vs control sites (5.4% [SD,15.8%]) (P = .20 and P = .11 for preintervention/postintervention
and hierarchical analyses, respectively). Both interventions tended to have
more impact at lower-volume CABG sites (for interaction: P = .04 for β-blockade; P = .02 for IMA
A multifaceted, physician-led, low-intensity CQI effort can improve
the adoption of care processes into national practice within the context of
a medical specialty society infrastructure.