Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: a randomized controlled trial

Context  A rigorous evaluation of continuous quality improvement (CQI) in medical practice has not been carried out on a national scale. Objective  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 -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. Intervention  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. Results  From January 2000 to July 2002, use of both process measures increased nationally (-blockade, 60.0%-65.6%; IMA grafting, 76.2%-82.8%). Use of -blockade increased significantly more at -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 -blockade; P = .02 for IMA grafting). Conclusions  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.