Do "America's best hospitals" perform better for acute myocardial infarction?

Background "America's Best Hospitals," an influential list published annually by U.S. News & World Report, assesses the quality of hospitals. It is not known whether patients admitted to hospitals ranked at the top in cardiology have lower short-term mortality from acute myocardial infarction than those admitted to other hospitals or whether differences in mortality are explained by differential use of recommended therapies. Methods Using data from the Cooperative Cardiovascular Project on 149,177 elderly Medicare beneficiaries with acute myocardial infarction in 1994 or 1995, we examined the care and outcomes of patients admitted to three types of hospitals: those ranked high in cardiology (top-ranked hospitals); hospitals not in the top rank that had on-site facilities for cardiac catheterization, coronary angioplasty, and bypass surgery (similarly equipped hospitals); and the remaining hospitals (non-similarly equipped hospitals). We compared 30-day mortality; the rates of use of aspirin, beta-blockers, and reperfusion; and the relation of differences in rates of therapy to shortterm mortality. Results Admission to a top-ranked hospital was associated with lower adjusted 30-day mortality (odds ratio, 0.87; 95 percent confidence interval, 0.76 to 1.00; P = 0.05 for top-ranked hospitals vs. the others). Among patients without contraindications to therapy, top-ranked hospitals had significantly higher rates of use of aspirin (96.2 percent, as compared with 88.6 percent for similarly equipped hospitals and 83.4 percent for non-similarly equipped hospitals; P < 0.01) and beta-blockers (75.0 percent vs. 61.8 percent and 58.7 percent, P < 0.01), but lower rates of reperfusion therapy (61.0 percent vs. 70.7 percent and 65.6 percent, P = 0.03). The survival advantage associated with admission to top-ranked hospitals was less strong after we adjusted for factors including the use of aspirin and beta-blockers (odds ratio, 0.94; 95 percent confidence interval, 0.82 to 1.08; P = 0.38). Conclusions Admission to a hospital ranked high on the list of "America's Best Hospitals" was associated with lower 30-day mortality among elderly patients with acute myocardial infarction. A substantial portion of the survival advantage may be associated with these hospitals' higher rates of use of aspirin and beta-blocker therapy. (N Engl J Med 1999;340: 286-92.) (C) 1999, Massachusetts Medical Society.