Individual Quality Measures Research Articles

The Team Formulation Quality Rating Scale (TFQS): development and evaluation

Background Team formulation is a core skill in mental health care, but there is currently no valid tool for assessing the quality of this process. Aim The aim of this study was to design and evaluate a new scale, the Team Formulation Quality Scale (TFQS), which assesses both structure and content. Methods Experts were asked to assess the relevance and clarity of each item on the TFQS to measure its content and face validity. Two experienced Clinical Psychologists rated eight audio recorded team formulation sessions and the scores were used to assess the internal consistency and inter-rater reliability of the TFQS. Results The TFQS demonstrated good content and face validity as experts agreed all twenty-three items were relevant to measuring the quality of team formulation and rated it as understandable and comprehensive. The overall internal consistency of the TFQS was good (alpha = 0.718). The inter-rater reliability of the TFQS was consistent with individual case formulation quality measures (ICC = 0.600). Conclusions We have developed the first scale to measure the quality of team formulation. The TFQS showed good validity and is a reliable tool that can be used in training, clinical practice and research related to team formulations.

Social media ratings of nursing homes associated with experience of care and \u201cNursing Home Compare\u201d quality measures

BackgroundSocial media platforms offer unique opportunities for patients and families to provide real-time feedback on their healthcare experiences. Consumer-generated social media ratings of hospitals tend to reflect the more subjective aspects of inpatient care experiences; however, evidence on nursing home care is extremely limited.MethodsWe collected consumer-reported 5-star ratings of Maryland nursing homes posted from July 2015 to July 2017 on 4 popular social media or online review sites (Facebook, Yelp, Google Consumer Reviews, and Caring.com). We determined if the average score of social media ratings was associated with experience-of-care ratings derived from survey of family members or other responsible parties of nursing home residents, and with “Nursing Home Compare” (NHC) 5-star ratings and individual quality measures.ResultsOne hundred ninety-six out of 206 nursing homes in Maryland were reviewed on at least one site and thus had one or more star ratings posted. The overall ratings were 3.11 on average on these sites and 3.03 on the NHC website, with a Pearson correlation of 0.41 (p < 0.001) between the 2 sets of ratings. The correlations between the social media rating and survey-based experience-of-care ratings ranged from 0.40 to 0.60, and the correlations between the social media rating and individual NHC quality measures of citations, nurse staffing, and complaints were about 0.35 (in absolute values). The social media rating also predicted well NHC and experience-of-care measures after adjusting for nursing home covariates and market competition.ConclusionsThe 5-star ratings collected from 4 social networking sites was correlated with and predictive of the NHC and survey-based experience-of-care measures for Maryland nursing homes.

Utilizing Dietary Nutrient Ratios in Nutritional Research: Expanding the Concept of Nutrient Ratios to Macronutrients.

We recently showed that using micronutrient ratios in nutritional research might provide more insights into how diet affects metabolism and health outcomes, based on the notion that nutrients, unlike drugs, are not consumed one at a time and do not target a single metabolic pathway. In this paper, we present a concept of macronutrient ratios, including intra- and inter-macronutrient ratios. Macronutrient intakes from food only, from the What We Eat in America website (summarized National Health and Nutrition Examination Survey data) were transposed into Microsoft Excel to generate ratios. Overall, the dietary ratios of macronutrients may be more revealing and useful in epidemiology and in basic nutritional research than focusing on individual protein, fat, and carbohydrate intakes. While macronutrient ratios may be applied to all types of nutritional research, nutritional epidemiology, and, ultimately, dietary guidelines, the methodology required has not been established yet. In the meantime, intra- and inter-macronutrient ratios may serve as a measure of individual and total macronutrient quality.

Quality Regulation? Access to High-Quality Specialists for Medicare Advantage Beneficiaries in California.

Medicare Advantage enrollment has seen tremendous growth over the past decade. However, we know comparatively little about the experience of beneficiaries in the program. Our knowledge of Medicare Advantage provider networks is particularly limited. This article is one of the first major assessments of the issue. It seeks to answer 3 important questions. First, are Medicare Advantage plan networks made up of higher quality providers? Second, how significant are the network restrictions imposed by Medicare Advantage plans with regard to access to higher quality providers? And finally, how much provider choice are Medicare Advantage beneficiaries left with? To assess these questions, I utilize geospatial data and individual provider quality measures for cardiologists, endocrinologists, and obstetricians and gynecologists from California. I find that Medicare Advantage beneficiaries generally do well in large metropolitan areas compared to traditional Medicare. However, there are concerns for those in micropolitan and rural areas, and even those in standard metropolitan areas, at times. Crucially, the connection between provider quality and networks can only be fully understood when connected to assessments of provider access. These findings also raise questions about how we think about provider networks and the adequacy of current approaches to network regulation.

Top Management Human Capital, Inventor Mobility, and Corporate Innovation

Using panel data on top management characteristics and a management quality factor constructed using common factor analysis on individual management quality measures, we analyze the relation between top firm management quality and corporate innovation input and output. We show that top management quality is an important determinant of corporate innovation, with individual aspects of management quality affecting innovation in younger and older firms differently. Further, firms with higher top management quality engage in more risky (“explorative”) innovation strategies. Finally, hiring more and higher-quality inventors is an important channel through which firms with higher management quality achieve greater innovation output.

India's Contribution and Research Impact Leishmaniasis Research: A Bibliometric Analysis

Background: Neglected Tropical Diseases identified by World Health Organization (WHO) have always been a challenge for the medical science and society. These diseases exerted high pressure on society in terms of financial, economic and psychological aspects. The three forms of Leishmaniosis (cutaneous, mucocutaneous and visceral) is one of the tropical diseases which is posing challenge in South America, East Africa, Middle East and South East Asian region. The various institutions and researchers are working towards the better health facilities. Objectives: The purpose of the study is to trace the growth of literature in leishmaniosis research for fifty years focusing the contribution and research impact made by India over global research. The specific objectives are to analyze the Indian research in terms of global publication and share, top productive countries compared with Indian research output, productive Indian institutions, authors, and their citation impact, journals publishing Indian research and highly cited articles published by Indian authors. Methods: The bibliographic data was obtained from SCOPUS database, for a period of fifty years (1968–2017) using keywords ‘leishmania’, ‘leishmaniasis’, ‘kala azar’, ‘kala-azar’ available in the title, abstract and keywords fields. The geographical location was kept ‘India’ to assess the publication and research impact for India. The citation scored by each article were taken as the number citation accumulated by the articles since its publication till 2017. The international collaboration by Indian authors in leishmaniasis was analyzed for the authors affiliation with international institutions. The individual quality measure was considered using Hirsch-index. Results: The SCOPUS has indexed 39302 articles on Leishmaniasis during the period of 1968 till 2017, of which there were 3391 published by Indian authors. It was 8.64% of global share, making it fifth most productive country on leishmaniasis research, while United States was most productive with 19.36% global share. In terms of citation count, Indian research have quite good impact and has been ranked fifth. Indian Institute of Chemical Biology was most productive Indian institute, but Banaras Hindu University Institute of Medical Sciences was most impact full. Conclusion: The continued efforts are being made to strengthen the better facilities for the research in Tropical and Neglected Disease care. The researcher working with the Indian leishmaniasis research are making good impact globally. Indian researchers have to go long way in order to eradicate the incidence of the leishmaniasis from Indian population. The results presented in this study shall be helpful for the perspective researchers and policy makers to analyse the strength of Indian Leishmaniasis research.

Quality of Endoscopy Reports for Esophageal Cancer Patients: Where Do We Stand?

Backgrounds and AimsAs treatment for esophageal cancer often involves a multidisciplinary approach, the initial endoscopic report is essential for communication between providers. Several guidelines have been established to standardize endoscopic reporting. This study evaluates the compliance of esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) reporting with the current national guidelines. MethodsCombining the National Comprehensive Cancer Network and Society of Thoracic Surgeons guidelines, 11 quality indicators (QIs) for EGD and 8 for EUS were identified. We evaluated initial EGD and EUS reports from our institution (Memorial Sloan Kettering [MSK]) and outside hospitals (OSHs) and calculated individual and overall quality measure scores. Scores between locations were compared using the Wilcoxon signed-rank test and McNemar’s test for paired data. ResultsIn total, 115 initial EGD reports and 105 EUS reports were reviewed for patients who underwent surgery for esophageal cancer between 2014 and 2016. The median number of QIs reported for the initial EGD was 4 (IQR, 3–6)—only 34% of reports qualified as “good quality” (those with ≥ 6 QIs). None of the reports included all QIs. For patients who underwent EGD at both MSK and an OSH, 32% of reports from OSHs were good quality, compared with 68% from MSK (p < 0.001). Compliance with QIs was better for EUS reports: 71% of OSH reports and 72% of MSK reports were good quality. ConclusionsDetailed information on the initial endoscopic assessment is essential in today’s age of multidisciplinary care. Identification and adoption of QIs for endoscopic reporting is warranted to ensure the provision of appropriate treatment.

Carotenoid metabolism strengthens the link between feather coloration and individual quality

Thirty years of research has made carotenoid coloration a textbook example of an honest signal of individual quality, but tests of this idea are surprisingly inconsistent. Here, to investigate sources of this heterogeneity, we perform meta-analyses of published studies on the relationship between carotenoid-based feather coloration and measures of individual quality. To create color displays, animals use either carotenoids unchanged from dietary components or carotenoids that they biochemically convert before deposition. We hypothesize that converted carotenoids better reflect individual quality because of the physiological links between cellular function and carotenoid metabolism. We show that feather coloration is an honest signal of some, but not all, measures of quality. Where these relationships exist, we show that converted, but not dietary, carotenoid coloration drives the relationship. Our results have broad implications for understanding the evolutionary role of carotenoid coloration and the physiological mechanisms that maintain signal honesty of animal ornamental traits.

The Dialysis Facility Compare Five-Star Rating System at 2 Years.

The 1997 Balanced Budget Act required the Centers for Medicare and Medicaid Services (CMS) to develop and implement a method to measure and report the quality of kidney dialysis services provided by Medicare ([1][1]). As a result, CMS launched the Dialysis Facility Compare (DFC) website in 2001,

Setting Quality Improvement Priorities for Women Receiving Systemic Therapy for Early-Stage Breast Cancer by Using Population-Level Administrative Data.

Purpose Routine evaluation of quality measures (QMs) can drive improvement in cancer systems by highlighting gaps in care. Targeting quality improvement at QMs that demonstrate substantial variation has the potential to make the largest impact at the population level. We developed an approach that uses both variation in performance and number of patients affected by the QM to set priorities for improving the quality of systemic therapy for women with early-stage breast cancer (EBC). Patients and Methods Patients with EBC diagnosed from 2006 to 2010 in Ontario, Canada, were identified in the Ontario Cancer Registry and linked deterministically to multiple health care databases. Individual QMs within a panel of 15 QMs previously developed to assess the quality of systemic therapy across four domains (access, treatment delivery, toxicity, and safety) were ranked on interinstitutional variation in performance (using interquartile range) and the number of patients who were affected; then the two rankings were averaged for a summative priority ranking. Results We identified 28,427 patients with EBC who were treated at 84 institutions. The use of computerized physician electronic order entry for chemotherapy, emergency room visits or hospitalizations during chemotherapy, and timely receipt of chemotherapy were identified as the QMs that had the largest potential to improve quality of care at a system level within this cohort. Conclusion A simple ranking system based on interinstitutional variation in performance and patient volume can be used to identify high-priority areas for quality improvement from a population perspective. This approach is generalizable to other health care systems that use QMs to drive improvement.

Describing the performance of U.S. hospitals by applying big data analytics.

Public reporting of measures of hospital performance is an important component of quality improvement efforts in many countries. However, it can be challenging to provide an overall characterization of hospital performance because there are many measures of quality. In the United States, the Centers for Medicare and Medicaid Services reports over 100 measures that describe various domains of hospital quality, such as outcomes, the patient experience and whether established processes of care are followed. Although individual quality measures provide important insight, it is challenging to understand hospital performance as characterized by multiple quality measures. Accordingly, we developed a novel approach for characterizing hospital performance that highlights the similarities and differences between hospitals and identifies common patterns of hospital performance. Specifically, we built a semi-supervised machine learning algorithm and applied it to the publicly-available quality measures for 1,614 U.S. hospitals to graphically and quantitatively characterize hospital performance. In the resulting visualization, the varying density of hospitals demonstrates that there are key clusters of hospitals that share specific performance profiles, while there are other performance profiles that are rare. Several popular hospital rating systems aggregate some of the quality measures included in our study to produce a composite score; however, hospitals that were top-ranked by such systems were scattered across our visualization, indicating that these top-ranked hospitals actually excel in many different ways. Our application of a novel graph analytics method to data describing U.S. hospitals revealed nuanced differences in performance that are obscured in existing hospital rating systems.

Impact of surgical training on the performance of proposed quality measures for hysterectomy for pelvic organ prolapse

Recent healthcare reform has led to increased emphasis on standardized provision of quality care. Use of government- and organization-approved quality measures is 1 way to document quality care. Quality measures, to improve care and aid in reimbursement, are being proposed and vetted in many areas of medicine. We aimed to assess performance of proposed quality measures that pertain to hysterectomy for pelvic organ prolapse stratified by surgical training. The 4 quality measures that we assessed were (1) the documentation of offering conservative treatment of pelvic organ prolapse, (2) the quantitative assessment of pelvic organ prolapse (Pelvic Organ Prolapse-Quantification or Baden-Walker), (3) the performance of an apical support procedure, and (4) the performance of cystoscopy at time of hysterectomy. Patients who underwent hysterectomy for pelvic organ prolapse from January 1 to December 31, 2008, within a large healthcare maintenance organization were identified by diagnostic and procedural codes within the electronic medical record. Medical records were reviewed extensively for demographic and clinical data that included the performance of the 4 proposed quality measures and the training background of the primary surgeon (gynecologic generalist, fellowship-trained surgeon in Female Pelvic Medicine and Reconstructive Surgery, and "grandfathered" Female Pelvic Medicine and Reconstructive Surgery). Data were analyzed with the use of descriptive statistics. Inferential statistics with chi-squared tests were used to compare performance rates of quality measures that were stratified by surgical training. Probability values <.05 were considered statistically significant. Six hundred thirty patients who underwent hysterectomy for pelvic organ prolapse in 2008 had complete records available for analysis. Fellowship-trained surgeons performed 302 hysterectomies for pelvic organ prolapse; grandfathered Female Pelvic Medicine and Reconstructive Surgery surgeons performed 98 hysterectomies, and gynecologic generalist surgeons performed 230 hysterectomies. Fellowship-trained surgeons had the highest performance rates for individual quality measures (91.4-98.7%) and cumulative performance of all measures (80.8% of cases). Grandfathered Female Pelvic Medicine and Reconstructive Surgery surgeons performed significantly fewer measures (80.6-95.9% performance rate for individual measures; 65.3% cumulatively for all measures) than fellowship-trained surgeons and more than gynecologic generalists (64.3-70% for individual measures; 29.1% cumulatively for all measures). There was an association between surgeon training background and number of hysterectomies performed for pelvic organ prolapse, with specialist surgeons performing more hysterectomies. When quality measure performance was stratified by surgeon volume, similar significant associations were found, with high-volume surgeons performing more quality measures than low-volume surgeons. Within a large healthcare maintenance organization, fellowship-trained Female Pelvic Medicine and Reconstructive Surgery surgeons were more likely to perform proposed quality measures in women who underwent hysterectomy for pelvic organ prolapse compared with those surgeons without such training. Grandfathered Female Pelvic Medicine and Reconstructive Surgery surgeons performed measures more frequently than gynecologic generalists but less than fellowship-trained surgeons. Further study is indicated to correlate the proposed quality measures with clinical outcomes.

Correlations Among Hospital Quality Measures: What "Hospital Compare" Data Tell Us.

A number of quality rating systems to rank health care providers have been developed over the years with the intention of helping consumers make informed health care purchasing decisions. Many use sets of individual quality measures to calculate a global rating. The utility of a global rating for consumer choice hinges on the relationships among included measures and the extent to which they jointly reflect an underlying dimension of quality. Publicly reported data on 4 quality domains-complication, mortality, readmission, and patient safety-from Centers for Medicare & Medicaid Services' Hospital Compare website were used to examine correlations among individual measures within each measure group (within-group correlations) and correlations between pairs of measures across different measure groups (between-group correlations). Modest within-group correlations were found in only 2 domains (mortality and readmission), and there were no meaningful between-group associations. These findings raise questions about whether consumers can reliably depend on global quality ratings to make informed decisions.

Correlations between quality ratings of skilled nursing facilities and multidrug-resistant urinary tract infections.

The purpose of this study was to determine risk factors for the acquisition of urinary tract infections (UTIs) and multidrug-resistant organisms (MDROs) in residents of skilled nursing facilities (SNFs). Using the informational database provided by the Centers for Medicare and Medicaid Services (CMS), a retrospective logistic regression was performed on 1,523 urine cultures from 12 SNFs located in Long Island, New York. Of the 1,142 positive urine cultures, Escherichia coli was most prevalent. Additionally, 164 (14.4%) of the UTIs were attributed to an MDRO. In multivariate logistic regression, sex and overall quality rating predicted the occurrence of UTIs, whereas identification of MDROs was dependent on the level of nursing care received. The mean predicted probability of UTIs and receipt of contaminated samples was inversely dependent on the facility's rating, where the likelihood increased as overall quality ratings decreased. The CMS's quality rating system may provide some insight into the status of infection control practices in SNFs. The results of this study suggest that potential consumers should focus on the overall star ratings and the competency of the nursing staff in these facilities rather than on individual quality measures.

A Historical Retrospective Analysis of the Impact of Diabetes Quality Measure Attainment on Outcomes in Medicare Advantage Members.

The objective of this study was to assess achievement of 4 diabetes mellitus (DM)-related quality measures (QMs) and examine the relationship between QM attainment, concurrent health care costs, and DM complications over 1 year by conducting a retrospective analysis of claims data for Medicare Advantage Prescription Drug plan members with DM. Claims and member-level quality data were used to assess QM achievement, concurrent health care costs, and presence of new or worsening DM complications during the QM year. Multivariable regression models were used to examine the relationship between QM achievement and outcome measures controlling for potentially confounding baseline characteristics. QM attainment rates ranged from 54.2% for DM Treatment measure to 83.4% for Cholesterol Screening measure. Odds of new or worsening complications were greater for members who did not meet the Blood Sugar Controlled performance goal (odds ratio [OR]: 1.12, P < 0.001), DM Treatment goal (OR: 1.40, P < 0.001), or Cholesterol Screening goal (OR: 1.32, P < 0.001). Failure to attain the DM Medication Adherence goal was associated with lower odds of new or worsening complications (OR: 0.94, P < 0.001). In the regression models, all-cause health care costs were greater for members who achieved the Blood Sugar Controlled quality goal (P < 0.001), but lower for members who attained DM Treatment (P < 0.001) and low-density lipoprotein Cholesterol Screening goals (P < 0.001). There was no statistically significant relationship between attaining the DM Medication Adherence measure and all-cause costs. Achievement rates for individual QMs varied across the study population and relationships between QM attainment, health care costs, and DM complications during the QM measurement year were mixed.

Exaggerated sexual swellings in female nonhuman primates are reliable signals of female fertility and body condition

In some species of Old World monkeys and apes, females exhibit exaggerated swellings of the anogenital region that vary in size across the ovarian cycle. Exaggerated swellings are typically largest around the time of ovulation, and swelling size has been reported to correlate positively with female quality, supporting the hypothesis that exaggerated swellings are honest signals of both female fecundity and quality. However, the relationship between swelling size and timing of ovulation is weak in some studies, and the relationship between swelling size and female quality has also not been consistently reported. Here, we collated empirical studies that have reported either swelling size and estimated timing of ovulation ( N = 26) or swelling size and measures of individual quality ( N = 7), to assess the strength of these relationships using meta-analytical methods. Our analyses confirmed that the period of maximal swelling size is closely associated with the most fertile period of the ovarian cycle and that a large proportion of ovulations occur during the maximal swelling period. A small, positive effect size was also found for the relationship between swelling size and body condition. In contrast, the relationships with age and social rank were not significant. Swelling size, therefore, potentially signals both female condition and timing of the fertile phase. Males are likely to benefit from allocating mating effort according to swelling size, while females with large swellings potentially benefit from exerting control over matings in species in which female control is compromised by male mating strategies.

Impact of the Rochester Medical Home Initiative on Primary Care Practices, Quality, Utilization, and Costs.

Patient-centered medical homes (PCMH) may improve the quality of primary care while reducing costs and utilization. Early evidence on the effectiveness of PCMH has been mixed. We analyze the impact of a PCMH intervention in Rochester NY on costs, utilization, and quality of care. A propensity score-matched difference-in-differences analysis of the effect of the PCMH intervention relative to a comparison group of practices. Qualitative interviews with PCMH practice managers on their experiences and challenges with PCMH practice transformation. Seven pilot practices and 61 comparison practices (average of 36,531 and 30,192 attributed member months per practice, respectively). Interviews with practice leaders at all pilot sites. Individual HEDIS quality measures of preventive care, diabetes care, and care for coronary artery disease. Utilization measures of hospital use, office visits, imaging and laboratory tests, and prescription drug use. Cost measures are inpatient, prescription drug, and total spending. After 3 years, PCMH practices reported decreased ambulatory care sensitive emergency room visits and use of imaging tests, and increased primary care visits and laboratory tests. Utilization of prescription drugs increased but drug spending decreased. PCMH practices reported increased rates of breast cancer screening and low-density lipid screening for diabetes patients, and decreased rates of any prevention quality indicator. The PCMH model leads to significant changes in patient care, with reductions in some services and increases in others. This study joins a growing body of work that finds no effect of PCMH transformation on total health care spending.

Does Quality of Care Matter? A Study of Adherence to National Comprehensive Cancer Network Guidelines for Patients with Locally Advanced Esophageal Cancer

IntroductionThe aim of this study was to assess whether adherence to National Comprehensive Cancer Network (NCCN) guidelines leads to differences in survival in patients diagnosed with locally advanced esophageal cancer. MethodsThis is a retrospective cohort study of patients with stage II and III esophageal cancer included in the Cancer Registry at the Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins Hospital from 2008 to 2013. Seven quality indicators were identified using the 2014 NCCN guidelines, and individual and overall quality measure scores were calculated and used to define low and high quality of care groups. ResultsOne hundred forty-one patients met inclusion criteria, and 88 patients (62.4 %) were identified as receiving high-quality care. Adherence to guidelines ranged from 63.1 to 100.0 %, with an overall compliance of 81.3 %. Risk factors for receiving low quality of care included advanced age, non-white race, lower education level, and unspecified primary site of tumor. A significantly better overall survival was observed in patients who received high-quality care (HR, 0.58; 95 %, 0.37–0.90, p = 0.015). ConclusionsDelivery of high-quality care is associated with improved survival in these patients. Efforts should be directed at minimizing disparities in treatment in regards to race and educational levels.

Prognostic impact of strengthening nursing intervention measures on ICU delirium patients

Objective To observe the related influence of strengthening nursing intervention measures and stimulating reasonable and effective nursing mode of individual quality. Methods 176 ICU delirium patients in our hospital were selected and divided into the observation group and the control group randomly. Patients in the observation group were given strengthening nursing intervention measures and division nursing, in the control group received conventional nursing. CAM- ICU scale, APACHE Ⅱ score table and ICDSC were used to evaluate patients in the 2 groups. Results Delirious state of the observation group was improved significantly compared with before treatment. Average score of ICDSC, CAM- ICU scale and APACHE Ⅱ score table of the observation group were reduced evidently compared with the control group. And the differences had statistical significances(P<0.05). Conclusion Taking strengthening nursing intervention measures combined with the measures of division nursing and individual quality nursing could improve effectively a variety of symptoms, reduce the use of sedative drugs, shorten delirium duration and improve the prognosis of patients. Key words: Delirium; ICU; Strengthening nursing; Intervention

Cluster-Randomized Trial of Personalized Site Performance Feedback in Get With The Guidelines-Heart Failure.

There is significant variation in the delivery of evidence-based care for patients with heart failure (HF), but there is limited evidence defining the best methods to improve the quality of care. We performed a cluster-randomized trial of personalized site performance feedback at 147 hospitals participating in the Get With The Guidelines-Heart Failure quality improvement program from October 2009 to March 2011. The intervention provided sites with specific data on their heart failure achievement and quality measures in addition to the usual Get With The Guidelines-Heart Failure tools. The primary outcome for our trial was improvement in site composite quality of care score. Overall, 73 hospitals (n=33 886 patients) received the intervention, whereas 74 hospitals (n=37 943 patients) did not. One year after the intervention, both the intervention and control arms had a similar mean change in percentage points in their composite quality score (absolute change, +0.31 [SE, 1.51] versus +3.18 [SE, 1.68] in control; P=0.21). Similarly, none of the individual achievement measures or quality measures improved more at intervention versus control hospitals. Our site-based intervention, which included personalized site feedback on adherence to quality metrics, was not able to elicit more quality improvement beyond that already associated with participation in the Get With The Guidelines-Heart Failure program. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00979264.