The purpose of this article is to describe factors contributing to potentially preventable mortality in academic medical centers and the organizational characteristics associated with success in reducing mortality. Sixteen U.S. academic medical centers that wished to improve risk-adjusted inpatient mortality rates requested a consultation that included interviews with physicians, nurses, and hospital leaders; review of medical records; and evaluation of systems and processes of care. The assessments took place on-site; they identified key factors contributing to preventable mortality, and each hospital received specific recommendations. Changes in observed mortality and in the ratio of observed to expected mortality were measured from 2002 to final follow-up in 2007. Evaluations determined each hospital's success factors and key barriers to improvement. The key factors contributing to preventable mortality were delays in responding to deteriorating patients, suboptimal critical care, hospital-acquired infections, postoperative complications, medical errors, and community issues such as the availability of hospice care. Of the 16 hospitals, 12 were able to reduce their mortality index. The five hospitals that had the greatest improvement in mortality were the only hospitals with a broad level of engagement among hospital and physician leaders, including the department chairs. In the hospitals whose performance did not improve, the department chairs were not engaged in the process. The academic medical centers that focused on mortality reduction and had engagement of physicians, especially department chairs, were able to achieve meaningful reductions in hospital mortality. The necessary ingredients for achieving meaningful improvement in clinical outcomes included good data, a sound method for change, and physician leadership.
Purpose: Although angiotensin-converting enzyme (ACE) inhibitors are recommended for all patients with systolic heart failure, prior studies suggest that elderly cohorts are less likely to receive such therapy. The purpose of this study was to determine the age dependence of adherence to guideline-based medical care in hospitalized heart failure patients. Methods: We performed a multicenter observational cohort study including 613 patients admitted to participating hospitals with a primary diagnosis of heart failure with ejection fraction ≤40%. This cohort was divided into four age groups (group 1: <60, group 2: 60–69, group 3: 70–79, and group 4: 80 years) and adherence to guideline-based medical care was measured. Results: ACE inhibitors were administered to 83% of ideal heart failure patients, and this rate was similar for all age groups. Elderly patients received significantly lower ACE inhibitor dosages compared to their younger counterparts (168, 148, 125 and 117 mg captopril in groups 1, 2, 3, and 4, respectively, p = 0.001). Lower creatinine clearance (p < 0.001), prior residence in a long-term care facility (p = 0.037), intolerance to ACE inhibitors (p = 0.006), lower blood pressure (p = 0.005), absence of a history of hypertension (p = 0.005), and no prior heart failure hospitalizations within the past year (p = 0.001) were found to be independent predictors of low ACE inhibitor dosing. Conclusions: In this heart failure benchmarking project, elderly patients received guideline-based ACE inhibitor therapy at similar rates, but at lower doses, compared to their younger counterparts.
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