The purpose of Medicare's Cooperative Cardiovascular Project (CCP) is to improve the care of Medicare patients presenting with acute myocardial infarction (AMI). MetaStar is Wisconsin's Medicare peer review organization that administers Phase II of the CCP. A major Phase II objective is to increase the use of reperfusion strategies (thrombolysis and angioplasty) and angiotensin converting enzyme (ACE) inhibitors (when the ejection fractions is < 40%) in patients presenting with AMI. After MetaStar presented Wausau Hospital's baseline Phase II data to us, we were asked to define a plan to improve the use of reperfusion therapy and ACE inhibitors. To verify the accuracy of the data presented to us, we reviewed the patient records used by MetaStar to calculate our baseline data for these 2 quality-of-care indicators. Our MetaStar reported reperfusion rate (48.4%) and ACE inhibitor rate (20.9%) were significantly different from that which we calculated (100% and 97%). Causes for the discrepancy included MetaStar abstractor's failure to exclude two patients who did not have an AMI, failure to correctly count patients who received the targeted treatment, and an inability of the abstractors to identify important CCP exclusion criteria. Thus, numerous patients who should have been excluded were inappropriately classified as "ideal" candidates for the targeted therapy. WE CONCLUDE: There are major flaws in the data collection techniques used by MetaStar in Phase II of the CCP. These flaws produced erroneous conclusions concerning our use of reperfusion strategies and ACE inhibitors. Since these quality-of-care indicators are major targeted goals of Phase II, the errors are of special concern. We believe better-designed abstract forms, due diligence, and more thorough training could have prevented the errors. In presenting our concerns, we hope to foster a response by MetaStar to improve the quality of the peer review process.