Adapted from industrial manufacturing principles in Japan and the United States, CQI in medicine is the repetitive cycle of process and outcomes measurement, design and implementation of interventions to improve the processes of care, and re-measurement to determine the effect on care quality. To date, successful CQI programs in medicine have been difficult to achieve due to a lack of appropriate information technology and organizational infrastructure.
This study utilized data from 359 hospitals participating in the Society of Thoracic Surgeons National Cardiac Database, funded by a grant from the Agency for Healthcare Research and Quality. Results were assessed among a total of 267,917 patients.
The objective of the study was to test whether low-intensity CQI interventions can be used to speed the national adoption of two coronary artery bypass grafting processes. Hospitals were prospectively randomized to receive one of two interventions designed to increase use of either preoperative beta-blocker therapy or IMA grafting in patients older than 75 years, or to a control group with no intervention. Preoperative beta-blocker therapy was chosen because of its protective effects and under use in cardiovascular disease patients. IMA grafting was chosen because its use has been demonstrated to prolong survival in younger patients, but at the start of the study, its use in elderly patients was considered controversial.
The trial tested whether a medical specialty society could leverage physician motivation nationally in a call to action at the local level. This initiative did not mandate the use of specific CQI tools, but rather allowed individual sites to determine how best to implement practice change at their own sites. The two measures were selected to test the implementation of new information into clinical practice through the CQI platform. Their link to outcomes was not established, particularly in context with the underlying ongoing decline in CABG mortality seen over the past decade. In the CQI trial, the beta-blocker therapy intervention had significant overall effect and the IMA intervention showed positive trends. Interestingly, sites with lower procedure volume had a higher incorporation of both measures than their high volume counterparts.
"This study suggests that a Medical Specialty Society CQI Platform can be the backbone of rapid, reliable, and beneficial translation of evidence into practice at the local physician level," said Dr. Ferguson, who is also principal investigator of the study. "A substantive increase in the use of two valuable CABG processes was accomplished in a 18-month time interval, far more rapidly than usually occurs in medicine."
Further refinements in this infrastructure and the CQI process are suggested by these results; however, the overall scope and success of this trial suggest a model that can be adopted by other providers for translating research into everyday practice, the researchers conclude.
Journal
JAMA