Date of Award


Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Judith Lichtman


Background: While mortality rates for cardiovascular disease have declined, many patients still fail to receive effective and timely care. Studies report that characteristics including census region of the United States (Midwest, West, Northeast and South), neighborhood classification (urban, rural, suburban), and teaching status are all associated with the quality of care provided. It has been reported that national quality improvement campaigns have been shown improve the quality of AMI care for these patients and increase compliance to guideline recommended treatment. Use of defect-free composite measures is increasing as they promote full execution of all processes of care, encourage a focus on the whole sequence of care instead of individual components, and offer a more sensitive scale to judge improvement in situations of already high compliance. The aforementioned hospital characteristics have not been analyzed using this defect-free composite measure as the outcome. This study aims to evaluate the degree to which hospital performance varied on the “all-or-none” composite measure and to identify hospital characteristics that were predictive of higher rates of defect-free care.

Methods: Using data from the National Cardiovascular Data Registry (NCDR) – Acute Coronary Treatment and Intervention Outcomes Network (ACTION) – Get With the Guidelines (AR-G) [NCDR AR-G] a total of 791,354 patients and 1,332 hospitals were analyzed. The “all-or-none” defect-free composite consisting of 11 ACC/AHA recommended guidelines was the primary outcome. The association between defect-free care and the hospital characteristics of interest was determined by multivariate logistic regression.

Results: Hospitals located in the Midwest and Northeast regions of the US were more likely to provide defect-free care (OR [95% CI]: 1.79 [1.73, 1.86] and 1.13 [1.07, 1.20], respectively) than hospitals in the South; while hospitals located in rural or suburban areas were less likely (OR [95% CI]: 0.83 [0.80, 0.87] and 0.95 [0.92, 0.98]) to provide defect-free care than hospitals in urban areas. In addition, teaching hospitals are less likely to provide defect-free care (OR [95% CI]: 0.96 [0.93, 0.99]) than hospitals that are non-teaching. Hospitals in all categories demonstrated positive trends in compliance throughout the study period.

Conclusions: In order to move from already high rates of compliance to full compliance, it must be recognized that hospital level variations in care still exist. This continued variation in care by hospital characteristics suggests that the institutions within each category face unique challenges. Studies are needed to identify these challenges and propose potential solutions.

Open Access

This Article is Open Access