Enhanced Feedback for Effective Cardiac Treatment - EFFECT — Presented at AHA 2009


The goal of this trial was to compare early feedback of a publicly released report compared with delayed feedback among hospitals who cared for patients admitted with acute myocardial infarction (AMI) or congestive heart failure (CHF).


Early feedback of public release of data on quality indicators would result in quality improvement.

Study Design

Study Design:

Primary Endpoints:

  • Composite AMI quality indicators
  • Composite CHF quality indicators

Drug/Procedures Used:

Randomization was performed at the hospital level. Hospitals were randomized to receive early feedback (n = 42) versus delayed feedback (n = 39) on data relating to quality measures.

Quality measures in the AMI group were:
  • standard admission orders
  • assessment of left ventricular (LV) function
  • lipid profile within 24 hours
  • lytics within 30 minutes or primary PCI within 90 minutes
  • lytics administered by an emergency physician
  • lytics administered prior to transfer to the coronary care unit
  • aspirin administered within 6 hours
  • beta-blocker administered within 12 hours
  • aspirin at discharge
  • beta-blocker at discharge
  • angiotensin-converting enzyme (ACE) inhibitor for LV dysfunction
  • statin at discharge

Quality measures in the CHF group were:
  • assessment of LV function
  • daily weights recorded
  • counseling on at least one aspect of heart failure
  • ACE inhibitor for LV dysfunction
  • beta-blocker for LV dysfunction
  • warfarin for atrial fibrillation

Principal Findings:

In the early feedback group, 12% of the participating hospitals were classified as teaching facilities and 74% as community. Among AMI patients, the median age was 69 years, 35% were women, and 27% were diabetics. Among CHF patients, the median age was 77 years, 51% were women, and 34% were diabetics.

The absolute change in the 12 AMI process of care indicators was 8.2% in the early feedback group versus 7.1% in the delayed feedback group (p = 0.43). The absolute change in the six CHF process of care indicators was -0.2% in the early feedback group versus 1.8% in the delayed feedback group (p = 0.81).

The absolute difference (early vs. delayed groups) in 30-day mortality for AMI was -2.5% (p = 0.045), for ST-elevation myocardial infarction (STEMI) was -3.1 (p = 0.04), for non-STEMI was -2.5 (p = 0.11), for CHF was -1.1 (p = 0.26), and for CHF with LV dysfunction was -1.2 (p = 0.44).


The early public release of hospital quality indicators did not improve composite quality scores for either AMI or CHF patients. It is possible that the treatment effect may have been diminished since hospitals in the delayed feedback group may have also been motivated to improve their quality practices due to media reporting on this topic. Although clinical outcomes were secondary, early feedback may have resulted in improved AMI mortality.


Tu JV, Donovan LR, Lee DS, et al. Effectiveness of public report cards for improving the quality of cardiac care. The EFFECT study: a randomized trial. JAMA 2009; Nov 18:[Epub ahead of print].

Presented by Dr. Jack Tu at the American Heart Association Scientific Sessions, Orlando, FL, November 18, 2009.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Dyslipidemia, Heart Failure and Cardiomyopathies, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Acute Heart Failure

Keywords: Quality Improvement, Myocardial Infarction, Coronary Care Units, Quality Indicators, Health Care, Warfarin, Lipids, Heart Failure, Counseling, Atrial Fibrillation, Diabetes Mellitus

< Back to Listings