The percentage of acute myocardial infarction (MI) patients whose door-to-balloon (D2B) time occurred within the recommended 90 minutes more than doubled between 2005 and 2010, according to a study in the Aug. 30 issue of Circulation. No one activity explains the improvement from a lackluster 44.2 percent in 2005 to 91.4 percent in 2010, the authors wrote, but rather a combination of initiatives and advancements contributed to the gain.
“Everyone had to improve to get a national report card like this,” said lead author Harlan M. Krumholz, MD, of the Yale University School of Medicine in New Haven, Conn., in a statement. “This remarkable achievement demonstrates what we can achieve if we work together.”
Krumholz and colleagues analyzed patient data submitted to the Centers for Medicare & Medicaid Services (CMS) between Jan. 1, 2005, and Sept. 30, 2010. The CMS measure was among several initiatives launched after a 2002 study found that only a third of patients received primary PCI within 90 minutes, a threshold that is associated with better outcomes. Nearly 250,000 patients in the U.S. experience ST-segment elevation MI each year.
The researchers’ goal was to determine if and to what degree the CMS quality indicator affected performance with a focus on D2B times of less than 90 minutes and less than 75 minutes. Based on CMS data for hospitals with at least five acute MI admissions a quarter, they summarized patient characteristics and evaluated trends for hospitals categorized by bed size, geographic region, ownership, location (urban vs. rural) and volume of patients with PCI. Summaries were done by calendar year, except for 2005, which covered three quarters.
They found that D2B time dropped from a year-end median of 96 minutes in 2005 to a median of 64 minutes through September 2010. The percentage of patients whose D2B time occurred within 90 minutes improved from 44.2 percent in 2005 to 91.4 percent in 2010. There were significant improvements in the 75 minute and under category as well, from 27.3 percent in 2005 to 70.4 percent in 2010.
Patient groups with the highest median times in 2005 also saw the greatest improvement, with patients older than 75 years experiencing a median decline of 38 minutes; women, a median decline of 35 minutes; and blacks, a median decline of 42 minutes.
Hospital analyses showed a similar pattern, with improvements most pronounced in hospitals that had the longest times previously. Hospitals with 500 or more beds saw their median times drop by 34 minutes; for-profits by a median 38 minutes; and the East-South Central and Mid-Atlantic regions by 40 minutes and 35 minutes, respectively.
“The improvements in D2B times that we observed cannot be definitively attributed to any single action: many activities likely contributed,” Krumholz and colleagues wrote. They listed national campaigns to raise awareness and improve timeliness, published research that identified strategies to improve care and the addition of hospitals’ D2B performance on a CMS’ Hospital Compare website as contributors. They highlighted the American College of Cardiology and American Heart Association's D2B Alliance and Mission: Lifeline as key initiatives.
At the same time, they acknowledged that changes in the exclusion criteria in CMS’ D2B measure in 2006 may have some effect on results. Starting in 2006, CMS allowed hospitals to exclude patients if there was a nonclinical reason for D2B delays.
D2B times could be further improved, the authors offered, by raising standards to the level of the best performers. Better coordination of care of transfer patients provides another opportunity, they wrote.
“The improvement demonstrates the results can be produced by collaboration among healthcare professionals, hospitals, federal research agencies and national organizations interested in patient care toward the achievement of a shared goal,” Krumholz and colleagues concluded. “The focus on improving the way in which care is delivered—improving the systems—has yielded more timely care for patients and serves as a template for similar contemporary and future efforts in areas such as readmission."