Regional Systems of Care for Patients With ST-Elevation Myocardial Infarction

Door-to-balloon times in hospitals within the get-with-the-guidelines registry after initiation of the door-to-balloon (D2B) Alliance

To improve hospital performance in door-to-balloon (DTB) times nationally, the American College of Cardiology D2B Alliance recently enrolled approximately 1,000 hospitals that perform percutaneous coronary intervention (PCI) across the United States in a large national quality improvement effort. We evaluated recent changes in DTB times in hospitals within the Get-With-The-Guidelines (GWTG) Coronary Artery Disease (CAD) program, a partner in the D2B Alliance. Within GWTG-CAD participating hospitals, we studied DTB in nontransferred patients with ST-elevation myocardial infarction treated with primary PCI from July 2006 to March 2008. We evaluated the percentage of patients treated within 90 minutes and used multivariable models with generalized estimating equations to examine trends over time after accounting for changes in patients' characteristics. A total of 5,801 patients at 167 hospitals were included in our analysis, with 3,567 patients at 98 hospitals that joined the D2B Alliance. From July to September 2006, 54.1% of patients received primary PCI within 90 minutes. This number increased significantly during the study period: 335 (74.1%) of 452 patients at GWTG-CAD participating hospitals were treated within 90 minutes from January to March 2008, including 229 of 304 patients (75.3%) treated at hospitals that joined the D2B Alliance and 106 of 148 patients (71.6%) treated at other GWTG-CAD participating hospitals (p <0.001 for all comparisons over time). No statistically significant differences were noted in the rate of change between hospitals that joined the D2B Alliance and other GWTG-CAD participating hospitals. In conclusion, the percentage of patients treated with 90 minutes has dramatically increased at hospitals participating within the GWTG-CAD program, coinciding with the launch of the D2B Alliance. These improvements were broad and not limited to hospitals that joined the D2B Alliance.

Achieving rapid reperfusion with primary percutaneous coronary intervention remains a challenge: insights from American Heart Association's Get With the Guidelines program

BACKGROUND

The speed of reperfusion (door-to-balloon [D2B] time) is a well established performance metric for patients with ST-elevation myocardial infarction. Although preferably D2B times should be <or=90 minutes, it is unclear how consistently this is achieved in community practice, particularly in women, elderly people, and minorities.

METHODS

We used the American Heart Association Get With the Guidelines database to study D2B times at 254 participating United States sites (2002-2006). Median D2B time and percentage of compliance with goal (percutaneous coronary interventions [PCI] <or=90 minutes) were assessed overall, over time, and among patient subgroups associated with the greatest delay in this time (older patients, women, and minorities). Standard generalized estimating equation was used to assess continuous trend, percentage of compliance (PCI <or=90 minutes) over time, and disparities in care based on race, sex, and age.

RESULTS

Over the study period, 10965 patients with ST-elevation myocardial infarction who met eligibility criteria received primary PCI (36% aged >or=65 years, 27% female, and 17% nonwhite). The overall median D2B time was 96 minutes (interquartile range [IQR] 69-140 minutes). Only 44.8% of cases had D2B <or=90 minutes. Median D2B time improved over the study period (108 minutes at baseline [fourth quarter of 2002] to 82 minutes by the last study quarter [third quarter of 2006], adjusted P = .001). The percentage achieving D2B <or=90 minutes also improved (36.2%-58.8%, adjusted P = .003). Relative to their peers, patients aged >or=65 years (103 [IQR 74-153] vs 93 [IQR 67-133] minutes), women (103 [IQR 73-154] vs 94 [IQR 68-135] minutes), and minorities (108 [IQR 77-162] vs 95 [IQR 68-136] minutes) had significantly longer median D2B times. These subgroup disparities in the D2B persisted over the study period as compared with their peers.

CONCLUSION

The median D2B times with primary PCI have improved modestly in hospitals participating in the American Heart Association Get With the Guidelines program over the last few years but remain below ideal levels. The D2B times are particularly delayed in the elderly people, women, and minority populations; an issue that has persisted over time. These results highlight the ongoing need for national myocardial infarction quality improvement initiatives.