An assessment of hospitals that perform primary PCI found a four-fold difference between facilities that frequently and rarely exclude patients based on non-system delays in reports on door-to-balloon (D2B) times. The variation affected compliance to the D2B metric.

David A. Cotoni, MD, of Virginia Commonwealth University in Richmond, and colleagues used the National Cardiovascular Data Registry’s Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) to study the frequency of non-system delays and their effect on D2B times. The registry database functions as the data collection and evaluation platform for the American Heart Association’s Mission: Lifeline STEMI program.

In 2007, Mission: Lifeline allowed hospitals to exclude patients with documented non-system delays in their D2B time submissions. The decision came one year after the Centers for Medicare & Medicaid Services (CMS) approved non-system delay exclusions. D2B times of 90 minutes or less have been shown to improve outcomes and are considered an indicator of quality care.  

“Numerous quality metrics, including D2B time, are publicly reported in an effort to compare outcomes and processes of care across hospitals,” Cotoni and colleagues wrote. “Importantly, the ability to meet certain metrics affects reimbursement through programs such as CMS ‘Pay for Performance’ program, with some private payers having similar performance metrics. The incentives to meet these goals may lead some to inappropriate[ly] exclude patients by claiming a non-systems delay.”

The researchers evaluated data on 43,909 patients from 294 hospitals that participated in the ACTION Registry-GWTG between January 2007 and March 2011 to calculate the proportion of patients with non-system delays at the hospital level.

They defined a non-system delay as either difficult vascular access, cardiac arrest or the need for intubation before PCI, consent delays, difficulty crossing the target lesion or other reasons. Hospitals were categorized based on the percentage of excluded patients, ranging from 7.1 percent or less (low) to more than 11.2 percent (high).

The 100 hospitals in the low exclusion group excluded 4 percent of patients and the 98 hospitals in the high exclusion group excluded 16.8 percent of patients, despite the patient populations being mostly similar. The most likely reason for exclusion in the low exclusion group was cardiac arrest and need for intubation. In the high exclusion group, it was difficulty crossing the target lesion.

The authors suggested difficulty crossing the target lesion might be more subjective than other criteria and a reflection of physician skill.

Overall, 82.9 percent of patients had D2B times of less than 90 minutes. That rose to 86.2 percent when patients with non-system delays were excluded and 87.5 percent for hospitals in the high exclusion group.

About one-fifth of hospitals had more than 90 percent of patients with D2B times of 90 minutes or less, which increased to 42.2 percent when excluding patients with non-system delays. Hospitals in the high exclusion group saw the greatest gains, jumping from 14.3 percent for all patients to 52 percent when patients with non-system delays were excluded.

Cotoni and colleagues offered several options to allay concerns that hospitals may be trying to game the system using non-system delays exclusions, including reporting D2B times without exclusions, auditing excluded patients and selectively auditing hospitals with the highest exclusion rates.

The study was published online April 16 in the American Journal of Cardiology.