The quality of quality: is it time for new tools?

O ver the past 2 decades, hydroxymethylglutaryl-CoA reductase inhibitors (statins) have taken center stage in the secondary prevention after myocardial infarction (MI) as evidence of their efficacy emerged from clinical trials. Practice guidelines then incorporated the results of clinical trials , and, because guideline-based care processes were shown to be associated with outcomes, 5 performance measures became an indicator of the quality of care. 6 Performance measures track whether or not evidence-based medications are administered after MI. However, they do not assess whether or not the dose is optimal. The dose is an important issue for statins, because their efficacy to prevent recurrent MI and death after the initial event has been shown to be greater at higher doses. The article by Arnold et al 8 in this issue of Circulation adds more depth to the conversation on quality of care after MI by examining the dose of statins that patients received after acute MI in an observational study. The authors report on data from the Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status (TRIUMPH) study. TRIUMPH is an National Heart, Lung, and Blood Institute–funded prospective registry designed to study the outcomes after MI with a distinct focus on health status outcomes in black and white patients. TRIUMPH collected detailed data on the socioeconomic, clinical, treatment, health status, metabolic, and genetic characteristics of patients with acute MI enrolled in 24 centers across the United States between 2005 and 2008. 9 The design of the TRIUMPH study included an extensive (5 hours) data collection process, and, on study completion, 4340 patients were eligible for analysis. The depth of the data collected in TRIUMPH provides an unprecedented opportunity to gain insights into critical aspects of the presentation, care, and outcome of patients with acute MI, and the report in the this issue of Circulation 8 illustrates such capabilities. The study describes statin initiation , and intensification and maximization of dose during MI hospitalization, as well, and reports both patient-level and hospital-level analyses. Statin initiation among previously untreated patients was high (87%) and uniform across sites. However, among previously treated patients, dose intensifica-tion occurred in only 26% of patients with moderate variation across sites, and only 23% of patients were discharged on maximal statin therapy with large differences in practice patterns across sites. Although one might argue that outpatient follow-up visits might be the time when dose escalation occurs, …