Abstract 174: Comparison of Performance Measures and 30-Day Patient Outcomes among Hospitals that Do and Do not Participate in ACTION Registry- Get With The Guidelines

Background: ACTION Registry-GWTG (ARG) is a clinical registry and Quality Improvement (QI) program co-sponsored by the American College of Cardiology and the American Heart Association, designed to measure and improve the treatment and outcomes of patients with acute myocardial infarction (AMI). However, it is unknown whether hospital participation in ARG is associated with better performance on publicly reported AMI quality metrics and 30-day outcomes.

Methods: Using Hospital Compare, we matched hospitals participating in ARG from 2007-2010 to non-ARG participating hospitals based on teaching status, hospital size, percutaneous coronary intervention capability, and composite adherence to AMI performance measures in 2007. We then used linear mixed modeling to compare 2010 performance measure adherence, 30-day mortality, and all-cause readmission among ARG and non-ARG hospitals. As secondary analyses, we repeated the matching process without using baseline adherence to AMI measures and also stratified the hospitals according to duration of ARG participation and level of baseline performance.

Results: We successfully matched 502 hospitals participating in ARG to 502 non-ARG hospitals. Adherence to AMI process measures was very high overall with minimal differences between ARG and non-ARG hospitals for most performance measures. In pairwise mixed modeling, ARG hospitals were more likely to achieve primary PCI within 90 minutes, though the absolute difference was small (Table). Overall, 30-day mortality and readmission rates were similar among ARG and non-ARG centers. Results were consistent whether hospitals were matched based on baseline performance or if centers were stratified by duration of ARG participation.

Conclusion: Hospitals across the U.S. report very high achievement rates for nearly all current performance measures for AMI care. These data suggest ongoing local and national QI efforts are having success within and beyond the ARG program. More sensitive process and outcome performance metrics with longer term outcomes may be needed to differentiate quality of care and drive the next phase of improvement in outcomes after acute coronary syndrome.

Prehospital system delay in ST-segment elevation myocardial infarction care: a novel linkage of emergency medicine services and in hospital registry data

BACKGROUND

Emergency medical services (EMS) are critical in the treatment of ST-segment elevation myocardial infarction (STEMI). Prehospital system delays are an important target for improving timely STEMI care, yet few limited data are available.

METHODS

Using a deterministic approach, we merged EMS data from the North Carolina Pre-hospital Medical Information System (PreMIS) with data from the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments-Emergency Response (RACE-ER) Project. Our sample included all patients with STEMI from June 2008 to October 2010 who arrived by EMS and who had primary percutaneous coronary intervention (PCI). Prehospital system delays were compared using both RACE-ER and PreMIS to examine agreement between the 2 data sources.

RESULTS

Overall, 8,680 patients with STEMI in RACE-ER arrived at a PCI hospital by EMS; 21 RACE-ER hospitals and 178 corresponding EMS agencies across the state were represented. Of these, 6,010 (69%) patients were successfully linked with PreMIS. Linked and notlinked patients were similar. Overall, 2,696 patients were treated with PCI only and were taken directly to a PCI-capable hospital by EMS; 1,750 were transferred from a non-PCI facility. For those being transported directly to a PCI center, 53% reached the 90-minute target guideline goal. For those transferred from a non-PCI facility, 24% reached the 120-minute target goal for primary PCI.

CONCLUSIONS

We successfully linked prehospital EMS data with in hospital clinical data. With this linked STEMI cohort, less than half of patients reach goals set by guidelines. Such a data source could be used for future research and quality improvement interventions.

Transport time and care processes for patients transferred with ST-segment-elevation myocardial infarction: the reperfusion in acute myocardial infarction in Carolina emergency rooms experience

BACKGROUND

For patients with ST-segment elevation myocardial infarction transferred for primary percutaneous coronary intervention, guidelines have called for device activation within 90 minutes of initial presentation. Fewer than 20% of transferred patients are treated in such a timely fashion. We examine the association between transfer drive times and door-to-device (D2D) times in a network of North Carolina hospitals. We compare the feasibility of timely percutaneous coronary intervention using ground versus air transfer.

METHODS AND RESULTS

We perform a retrospective analysis of the relationship between transfer drive times and D2D times in a 119-hospital ST-segment-elevation myocardial infarction statewide network. Between July 2008 and December 2009, 1537 ST-segment-elevation myocardial infarction patients underwent interhospital transfer for reperfusion via primary percutaneous coronary intervention. For ground transfers, median D2D time was 93 minutes for drive times ≤30 minutes, 117 minutes for drive times of 31 to 45 minutes, and 121 minutes for drive times >45 minutes. For air transfers, median D2D time was 125 minutes for drive times of 31 to 45 minutes and 138 minutes for drive times >45 minutes. Helicopter transport was associated with longer door-in door-out times and, ultimately, was associated with median D2D times that exceeded guideline recommendations, no matter the transfer drive time category.

CONCLUSIONS

In a well-developed ST-segment-elevation myocardial infarction system, D2D times within 90 to 120 minutes appear most feasible for hospitals within 30-minute transfer drive time. Helicopter transport did not offer D2D time advantages for transferred STEMI patients. This finding appears to be attributable to comparably longer door-in door-out times for air transfers.

Systems of Care for ST-Segment–Elevation Myocardial Infarction: A Report From the American Heart Association’s Mission: Lifeline

Background—

National guidelines call for participation in systems to rapidly diagnose and treat ST-segment–elevation myocardial infarction (STEMI). In order to characterize currently implemented STEMI reperfusion systems and identify practices common to system organization, the American Heart Association surveyed existing systems throughout the United States.

Methods and Results—

A STEMI system was defined as an integrated group of separate entities focused on reperfusion therapy for STEMI within a geographic region that included at least 1 hospital that performs percutaneous coronary intervention and at least 1 emergency medical service agency. Systems meeting this definition were invited to participate in a survey of 42 questions based on expert panel opinion and knowledge of existing systems. Data were collected through the American Heart Association Mission: Lifeline website.

Between April 2008 and January 2010, 381 unique systems involving 899 percutaneous coronary intervention hospitals in 47 states responded to the survey, of which 255 systems (67%) involved urban regions. The predominant funding sources for STEMI systems were percutaneous coronary intervention hospitals (n = 320, 84%) and /or cardiology practices (n = 88, 23%). Predominant system characteristics identified by the survey included: STEMI patient acceptance at percutaneous coronary intervention hospital regardless of bed availability (N = 346, 97%); single phone call activation of catheterization laboratory (N = 335, 92%); emergency department physician activation of laboratory without cardiology consultation (N = 318, 87%); data registry participation (N = 311, 84%); and prehospital activation of the laboratory through emergency department notification without cardiology notification (N = 297, 78%). The most common barriers to system implementation were hospital (n = 139, 37%) and cardiology group competition (n = 81, 21%) and emergency medical services transport and finances (n = 99, 26%).

Conclusions—

This survey broadly describes the organizational characteristics of collaborative efforts by hospitals and emergency medical services to provide timely reperfusion in the United States. These findings serve as a benchmark for existing systems and should help guide healthcare teams in the process of organizing care for patients with STEMI.

Rates of Cardiac Catheterization Cancelation for ST-Segment Elevation Myocardial Infarction After Activation by Emergency Medical Services or Emergency Physicians

Background—

For patients with an acute ST-segment elevation myocardial infarction, cardiac catheterization laboratory (CCL) activation by emergency medical technicians or emergency physicians has been shown to substantially reduce treatment times. One drawback to this approach involves overtriage, whereby CCL staffs are activated for patients who ultimately do not require emergent coronary angiography or for patients who undergo angiography but are not found to have coronary artery occlusion.

Methods and Results—

We examined CCL activation at 14 primary angioplasty hospitals to determine the course of management, including the rate of inappropriate activation. Among 3973 activations (29% by emergency medical technicians, 71% by emergency physicians) between December 2008 and December 2009, appropriate CCL activations occurred for 3377 patients (85%), with 2598 patients (76.9% of appropriate activations) receiving primary percutaneous coronary intervention. Reasons for inappropriate activations (596 patients; 15%) included ECG reinterpretations (427 patients; 72%) or the fact that the patient was not a CCL candidate (169 patients; 28%). The rate of cancellation because of reinterpretation of emergency medical technicians' ECG (6% of all activations) was more common than for cancellation because of reinterpretation of emergency physicians' ECG (4.6%).

Conclusions—

This represents the first report of the rates of CCL cancellation for ST-segment elevation myocardial infarction system activation by emergency medical technicians and emergency physicians in a large group of hospitals organized within a statewide program. The high rate of coronary intervention and relatively low rate of inappropriate activation suggest that systematic CCL activation by emergency personnel on a broad scale is feasible and accurate, and these rates set a benchmark for ST-segment elevation myocardial infarction systems.

Care Processes Associated With Quicker Door-In–Door-Out Times for Patients With ST-Elevation–Myocardial Infarction Requiring Transfer

Background—

The ability to rapidly identify patients with ST-segment elevation–myocardial infarction (STEMI) at hospitals without percutaneous coronary intervention (PCI) and transfer them to hospitals with PCI capability is critical to STEMI regionalization efforts. Our objective was to assess the association of prehospital, emergency department (ED), and hospital processes of care implemented as part of a statewide STEMI regionalization program with door-in–door-out times at non-PCI hospitals.

Methods and Results—

Door-in–door-out times for 436 STEMI patients at 55 non-PCI hospitals were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of standardized protocols as part of a statewide regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, RACE). The association of 8 system care processes (encompassing emergency medical services [EMS], ED, and hospital settings) with door-in–door-out times was determined using multivariable linear regression. Median door-in–door-out times improved significantly with the intervention (before: 97.0 minutes, interquartile range, 56.0 to 160.0 minutes; after: 58.0 minutes, interquartile range, 35.0 to 90.0 minutes; P <0.0001). Hospital, ED, and EMS care processes were each independently associated with shorter door-in–door-out times (−17.7 [95% confidence interval, −27.5 to −7.9]; −10.1 [95% confidence interval, −19.0 to −1.1], and −7.3 [95% confidence interval, −13.0 to −1.5] minutes for each additional hospital, ED, and EMS process, respectively). Combined, adoption of EMS processes was associated with the shortest median treatment times (44 versus 138 minutes for hospitals that adopted all EMS processes versus none).

Conclusions—

Prehospital, ED, and hospital processes of care were independently associated with shorter door-in–door-out times for STEMI patients requiring transfer. Adoption of several EMS processes was associated with the largest reduction in treatment times. These findings highlight the need for an integrated, system-based approach to improving STEMI care.

Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention

CONTEXT

Patients with ST-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention (PCI) often have prolonged overall door-to-balloon (DTB) times from first hospital presentation to second hospital PCI. Door-in to door-out (DIDO) time, defined as the duration of time from arrival to discharge at the first or STEMI referral hospital, is a new clinical performance measure, and a DIDO time of 30 minutes or less is recommended to expedite reperfusion care.

OBJECTIVE

To characterize time to reperfusion and patient outcomes associated with a DIDO time of 30 minutes or less.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort of 14,821 patients with STEMI transferred to 298 STEMI receiving centers for primary PCI in the ACTION Registry-Get With the Guidelines between January 2007 and March 2010.

MAIN OUTCOME MEASURES

Factors associated with a DIDO time greater than 30 minutes, overall DTB times, and risk-adjusted in-hospital mortality.

RESULTS

Median DIDO time was 68 minutes (interquartile range, 43-120 minutes), and only 1627 patients (11%) had DIDO times of 30 minutes or less. Significant factors associated with a DIDO time greater than 30 minutes included older age, female sex, off-hours presentation, and non-emergency medical services transport to the first hospital. Patients with a DIDO time of 30 minutes or less were significantly more likely to have an overall DTB time of 90 minutes or less compared with patients with DIDO times greater than 30 minutes (60% [95% confidence interval {CI}, 57%-62%] vs 13% [95% CI, 12%-13%]; P < .001). Among patients with DIDO times greater than 30 minutes, only 0.6% (95% CI, 0.5%-0.8%) had an absolute contraindication to fibrinolysis. Observed in-hospital mortality was significantly higher among patients with DIDO times greater than 30 minutes vs patients with DIDO times of 30 minutes or less (5.9% [95% CI, 5.5%-6.3%] vs 2.7% [95% CI, 1.9%-3.5%]; P < .001; adjusted odds ratio for in-hospital mortality, 1.56 [95% CI, 1.15-2.12]).

CONCLUSION

A DIDO time of 30 minutes or less was observed in only a small proportion of patients transferred for primary PCI but was associated with shorter reperfusion delays and lower in-hospital mortality.

Impact of a statewide ST-segment-elevation myocardial infarction regionalization program on treatment times for women, minorities, and the elderly

BACKGROUND

Prior studies have demonstrated differences in time to reperfusion for ST-segment-elevation myocardial infarction (STEMI) in women, minorities, and the elderly, relative to their counterparts. Regionalization has been shown to improve overall STEMI treatment times, but its impact on care differences among these important patient subgroups is unknown. The objective of this analysis was to assess the impact of a statewide system of STEMI care (The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) on treatment times according to patient sex, race, and age.

METHODS AND RESULTS

STEMI treatment times were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of coordinated regional treatment protocols. Times in the pre- and postintervention periods were compared by mixed-effects models. A total of 2063 STEMI patients were analyzed: 1140 at percutaneous coronary intervention hospitals and 923 at non-percutaneous coronary intervention hospitals. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments was associated with significant improvements in treatment times in women and the elderly, including door-to-ECG, door-to-device, door-in-door-out, and door-to-needle times (all P<0.05). Temporal improvements in treatment times at percutaneous coronary intervention hospitals were not significantly different in blacks than in whites. There was a reduction in baseline treatment disparities in door-to-ECG times in women versus men (4.4-minute reduction in difference; 95% CI, -8.1 to -0.4; P=0.03). After Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, an age-treatment time gap persisted in the elderly, relative to younger patients.

CONCLUSIONS

A statewide STEMI regionalization program was associated with comparable improvement in treatment times for female, black, and elderly patients compared with middle-aged, white male patients. Nevertheless, there remain opportunities to further narrow treatment differences, particularly among the elderly.

Certificate of Need (CON) for cardiac care: controversy over the contributions of CON

OBJECTIVES

To test whether state Certificate of Need (CON) regulations influence procedural mortality or the provision of coronary artery bypass graft surgery (CABG) and percutaneous coronary interventions (PCI).

DATA SOURCES

Medicare inpatient claims obtained for 1989-2002 for patients age 65+ who received CABG or PCI.

STUDY DESIGN

We used differences-in-differences regression analysis to compare states that dropped CON during the sample period with states that kept the regulations. We examined procedural mortality, the number of hospitals in the state performing CABG or PCI, mean hospital volume, and statewide procedure volume for CABG and PCI.

PRINCIPAL FINDINGS

States that dropped CON experienced lower CABG mortality rates relative to states that kept CON, although the differential is not permanent. No such mortality difference is found for PCI. Dropping CON is associated with more providers statewide and lower mean hospital volume for both CABG and PCI. However, statewide procedure counts remain the same.

CONCLUSIONS

We find no evidence that CON regulations are associated with higher quality CABG or PCI. Future research should examine whether the greater number of hospitals performing revascularization after CON removal raises expenditures due to the building of more facilities, or lowers expenditures due to enhanced price competition.

Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial

OBJECTIVES

The purpose of this study was to evaluate the diagnostic accuracy of electrocardiographically gated 64-multidetector row coronary computed tomographic angiography (CCTA) in individuals without known coronary artery disease (CAD).

BACKGROUND

CCTA is a promising method for detection and exclusion of obstructive coronary artery stenosis. To date, no prospective multicenter trial has evaluated the diagnostic accuracy of 64-multidetector row CCTA in populations with intermediate prevalence of CAD.

METHODS

We prospectively evaluated subjects with chest pain at 16 sites who were clinically referred for invasive coronary angiography (ICA). CCTAs were scored by consensus of 3 independent blinded readers. The ICAs were evaluated for coronary stenosis based on quantitative coronary angiography (QCA). No subjects were excluded for baseline coronary artery calcium score or body mass index.

RESULTS

A total of 230 subjects underwent both CCTA and ICA (59.1% male; mean age: 57 +/- 10 years). On a patient-based model, the sensitivity, specificity, and positive and negative predictive values to detect > or =50% or > or =70% stenosis were 95%, 83%, 64%, and 99%, respectively, and 94%, 83%, 48%, 99%, respectively. No differences in sensitivity and specificity were noted for nonobese compared with obese subjects or for heart rates < or =65 beats/min compared with >65 beats/min, whereas calcium scores >400 reduced specificity significantly.

CONCLUSIONS

In this prospective multicenter trial of chest pain patients without known CAD, 64-multidetector row CCTA possesses high diagnostic accuracy for detection of obstructive coronary stenosis at both thresholds of 50% and 70% stenosis. Importantly, the 99% negative predictive value at the patient and vessel level establishes CCTA as an effective noninvasive alternative to ICA to rule out obstructive coronary artery stenosis. (A Study of Computed Tomography [CT] for Evaluation of Coronary Artery Blockages in Typical or Atypical Chest Pain; NCT00348569).

Pannus-related prosthetic valve dysfunction and life-threatening aortic regurgitation

Prosthetic valve dysfunction is a rare but life-threatening condition. A 66-year-old woman presented with shock 15 years after aortic valve replacement with a tilting-disc valve. Imaging demonstrated severe aortic insufficiency and a fixed-open prosthetic valve. Reoperation revealed pannus ingrowth from the aortic aspect, resulting in immobility of the occluder. A bioprosthetic valve was installed and the patient recovered uneventfully. The diagnosis and surgical management of this problem are discussed.

Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction

CONTEXT

Despite 2 decades of evidence demonstrating benefits from prompt coronary reperfusion, registries continue to show that many patients with ST-segment elevation myocardial infarction (STEMI) are treated too slowly or not at all.

OBJECTIVE

To establish a statewide system for reperfusion, as exists for trauma care, to overcome systematic barriers.

DESIGN AND SETTING

A quality improvement study that examined the change in speed and rate of coronary reperfusion after system implementation in 5 regions in North Carolina involving 65 hospitals and associated emergency medical systems (10 percutaneous coronary intervention [PCI] hospitals and 55 non-PCI hospitals).

PATIENTS

A total of 1164 patients with STEMI (579 preintervention and 585 postintervention) eligible for reperfusion were treated at PCI hospitals (median age 61 years, 31% women, 4% Killip class III or IV). A total of 925 patients with STEMI (518 preintervention and 407 postintervention) were treated at non-PCI hospitals (median age 62 years, 32% women, 4% Killip class III or IV).

INTERVENTIONS

Early diagnosis and the most expedient coronary reperfusion method at each point of care: emergency medical systems, emergency department, catheterization laboratory, and transfer. Within 5 regions, PCI hospitals agreed to provide single-call catheterization laboratory activation by emergency medical personnel, accept patients regardless of bed availability, and improve STEMI care for the entire region regardless of hospital affiliation.

MAIN OUTCOME MEASURES

Reperfusion times and rates 3 months before (July to September 2005) and 3 months after (January to March 2007) a year-long implementation.

RESULTS

Median reperfusion times significantly improved according to first door-to-device (presenting to PCI hospital 85 to 74 minutes, P < .001; transferred to PCI hospital 165 to 128 minutes, P < .001), door-to-needle in non-PCI hospitals (35 to 29 minutes, P = .002), and door-in to door-out for patients transferred from non-PCI hospitals (120 to 71 minutes, P < .001). Nonreperfusion rates were unchanged (15%) in non-PCI hospitals and decreased from 23% to 11% in the PCI hospitals. For patients presenting to or transferred to PCI hospitals, clinical outcomes including death, cardiac arrest, and cardiogenic shock did not significantly change following the intervention.

CONCLUSIONS

A statewide program focused on regional systems for reperfusion for STEMI can significantly improve quality of care. Further research is needed to ensure that programs that result in improved application of reperfusion treatments will lead to reductions in mortality and morbidity from STEMI.

Training cardiovascular specialists in imaging: a curriculum based on fundamental concepts required for multimodal imaging

BACKGROUND

Training cardiovascular (CV) imaging specialists is becoming increasingly complex owing to rapidly emerging technological advances and the growing recognition that single modality training is inefficient and results in suboptimal education and practice. The purpose of this document was to propose a multimodality CV imaging curriculum to improve training of future CV imaging specialists.

METHODS

Relevant national standards relating to aiming training, competence, and quality were reviewed, including current training recommendations from the American College of Cardiology and requirements from the Accreditation Council for Graduate Medical Education. Experts from all imaging modalities identified areas of commonality that could create efficiencies in training. Finally, the proposed curriculum was placed within the context of a standard 3-year fellowship training program with optional advanced imaging training.

RESULTS

Multimodality imaging training can be accomplished efficiently and effectively for most trainees by introducing a curriculum of imaging didactic content broadly based on understanding basic cardiovascular anatomy and physiology, principles of performing quality CV imaging, and imaging in the broader health care environment. A curriculum and training program are proposed that satisfy level 2 training in 2 to 3 modalities and level 3 training in 1 modality in a traditional 3-year fellowship.

CONCLUSIONS

Training cardiovascular specialists to be competent in multimodality imaging is possible based on the proposed curriculum and training program within a traditional 3-year cardiovascular fellowship. Imaging specialists may require additional training.

Echocardiographic risk stratification for early surgery with endocarditis: a cost-effectiveness analysis

BACKGROUND

Despite widespread acceptance of echocardiography for diagnosis of infective endocarditis, few investigators have evaluated its utility as a risk-stratification tool to aid therapeutic decision-making.

METHODS

A decision tree and Markov analysis model were constructed using published and institutional data to estimate the cost-effectiveness of an echocardiographic risk-stratification strategy for infective endocarditis. The models compared surgery for high-risk patients based on clinical factors ("standard care") and surgery for high-risk patients based on echocardiographic findings ("echocardiography-guided").

RESULTS

The cost per patient for standard care and echocardiography-guided strategies was $47,766 and $53,669, respectively. The expected quality-adjusted life years (QALY) for standard care and echocardiography-guided strategies were 5.86 years and 6.10 years, respectively. Compared with standard care, the echocardiography-guided strategy cost an additional $23,867 per QALY saved. In one-way sensitivity analyses, the incremental cost of this strategy remained <$50,000/QALY across a broad range of scenarios. Baseline stroke risk had the greatest effect on cost-effectiveness. For populations with stroke risk less than 3.65%, the echocardiography-guided strategy was not cost-attractive (ICER >$50,000/QALY). At stroke risk between 3.65% and 14%, the ICER for the echocardiography-guided strategy was attractive (<$50,000 /QALY). The echocardiography-guided strategy became economically dominant at any baseline stroke risk greater than 18.3%.

CONCLUSION

Echo-guided risk stratification for early surgery in patients with large vegetations is a cost-attractive treatment strategy for IE, as it improves outcome for an incremental cost <$50,000/QALY.