CARDIOVASCULAR DISEASE REMAINS THE MOST COMmon cause of morbidity and mortality in the United States, and each year an estimated 785 000 US residents will have a new myocardial infarction (MI), and approximately 470 000 will have a recurrent MI. ST-segment elevation myocardial infarction (STEMI) constitutes a subset of MI presentation, defined by characteristic symptoms of myocardial ischemia and associated with ST-segment elevation or new or presumed new left bundle-branch block. Among patients presenting with an MI, the percentage of cases with STEMI varies in different registries and databases. According to the National Registry of Myocardial Infarction 4 (NRMI-4), among all patients with MI, approximately 29% present with STEMI. The optimal treatment of STEMI has significantly changed during the last decade with the incorporation of evidence from multiple clinical trials into clinical practice guidelines that emphasize the importance of rapid reperfusion and the use of evidence-based therapies to reduce morbidity and mortality. Multiple studies have suggested that improving trends in survival after an acute MI are associated with increasing use of evidence-based treatments and timely reperfusion therapies during the initial admission to the hospital. In this issue of JAMA, Jernberg and colleagues report that in a national Swedish registry of patients with STEMI, between 1996 and 2007, there was an overall increase in the use of evidence-based treatments. This increase coincided with a decrease in 30-day and 1-year mortality that was sustained during long-term follow-up. Although causality between increase in evidence-based therapies and decreased mortality cannot be established given the study design, the study does provide valuable insights into STEMI management. One important finding is the large variation in the implementation of evidence-based and guidelinerecommended treatments between different hospitals, and another is the inherently gradual and slow adoption of such therapies. The results have significant clinical implications for clinicians, hospitals, and patients. They point to an opportunity to improve the quality of care provided to patients with STEMI by decreasing the lag time for adoption of lifesaving therapies and improving adherence to evidencebased care across hospitals. The difficulty in disseminating and implementing new technology as reported in the current study is not unique to health care; the slow adoption of innovation has been documented in fields as different as agriculture, education, and communication. Successful training of clinicians in implementing new therapies requires a balance of both didactic training, defined as the methods used for information transfer such as written materials, lectures, and workshops, and competence training, defined as the process of acquiring skills necessary to administer a treatment skillfully and with fidelity. Quality improvement exercises that promote the use of systems that embed guideline knowledge into the care process are often more successful than simple dissemination of information. The creation of systems and the inclusion of the patient, nurse, and physician in a review of care priorities are methods that promote improvement in quality of health care. Three strategies that define successful quality improvement initiatives include involvement of all stakeholders (such as physicians, patients, nurses, pharmacists, and hospital administrators), emphasis on standard orders and discharge tools that remind clinicians to consider evidence-based therapies for every patient from admission to discharge, and rapid or concurrent and continuous feedback to physicians on use of appropriate evidence-based therapies. Any intervention aiming to modify physician behavior also must be effective in supporting the adoption of changes into clinical practice. In a review assessing the relative success of interventions in clinical practice, Tamblyn and Battista grouped the factors that affect change into predisposing, enabling, and reinforcing factors. The authors found that interventions designed to modify the enabling and reinforcing factors seem to be more effective than those aimed at