JAMA: Most patients don't meet recommended transfer times

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While PCI is the guideline-recommended care for STEMI patients, 75 percent of U.S. hospitals currently do not have these capabilities, which has resulted in more patients requiring transfers to STEMI hospitals. Researchers has found that door-in to door-out times (DIDO), a new clinical performance measure defined as the time from arrival to discharge at the first or STEMI referral hospital, were more than 30 minutes longer than those recommended.

For the analysis, published in the June 21 issue of the Journal of the American Medical Association, Tracy Y. Wang, MD, of the Duke Clinical Research Institute at the Duke University Medical Center in Durham, N.C., and colleagues performed a retrospective study of 14,821 STEMI patients who were transferred to 298 STEMI receiving centers to undergo PCI in the ACTION Registry-Get With the Guidelines between January 2007 and March 2010.

Wang and colleagues analyzed the factors associated with having a DIDO time greater than 30 minutes, overall door-to-balloon (D2B) times and risk-adjusted hospital mortality.

The authors wrote that DIDO “is increasingly being advocated as an important metric of processes of care to expedite reperfusion, and a national benchmark of less than 30 minutes has been recommended,” by various societies including the American Heart Association, American College of Cardiology and the Centers for Medicare & Medicaid Services.

The researchers reported median DIDO times to be 68 minutes, 38 minutes longer than what is recommended. In fact, only 1,627 patients during the study had a DIDO time that was 30 minutes or less. Meanwhile, 56 percent had DIDO times greater than 60 minutes and 35 percent had DIDO times that were greater than 90 minutes.

Additionally, the researchers noted that patients with DIDO times greater than 30 minutes were more likely to be older, female and have more comorbidities compared with patients who had DIDO times of 30 minutes or less.

Median D2B times were reported to be 120 minutes and only 19 percent of  patients achieved recommended D2B times of 90 minutes or less. However, D2B times were shorter for those who had DIDO times of 30 minutes or less compared with those who had DIDO times that were greater than 30 minutes. The number of patients with overall D2B times of 90 minutes or less was higher for patients with DIDO times of 30 minutes or less compared with those with a DIDO time greater than 30 minutes (60 vs.13 percent).

In-hospital morality rates were higher in patients with a DIDO time greater than 30 minutes (5.9 percent) compared with patients who had a DIDO time of 30 minutes or less (2.7 percent), the researchers found.

“The timeliness of reperfusion therapy for STEMI patients transferred for primary PCI is often prolonged, with only a minority of transferred patients achieving a guideline-recommended overall DTB time of less than 90 minutes,” the authors wrote.

Only 11 percent of patients within the study met the recommended DIDO times of 30 minutes or less. “Our study shows that while there has been a significant downward secular trend in DIDO time, only one in 10 patients achieved a DIDO time of 30 minutes or less at the STEMI referral hospital,” the authors wrote. Because these DIDO times were so prolonged, 90 minute D2B were “realistically unachievable.”

The researchers concluded that these results show the importance of regional networks of coordinated STEMI care.