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Door-to-balloon times on decline for patients undergoing primary PCI
Krumholz HM. Circulation. 2011;124:1038-1045.
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Patients with STEMI undergoing primary percutaneous coronary intervention had significantly improved door-to-balloon times during a 5-year period, a study published in Circulation indicated.
In the study, researchers analyzed data from hospitals that reported to CMS all patients who underwent PCI from 2005 to September 2010.
According to results, patients were constant throughout the 6-year study period, ranging from 48,977 to 53,682. The number of patients reported by hospitals increased from 896 to 973.
By the end of the study period, door-to-balloon times declined from a median of 96 minutes to 64 minutes. Researchers found that patients who had the greatest median time decline were patients aged older than 75 years (median decline, 38 minutes), women (35 minutes) and blacks (42 minutes). Researchers also found an increase in patients with percentages of door-to-balloon times of less than 90 minutes (44.2% to 91.4%) and less than 75 minutes (27.3% and 70.4%).
Among groups of hospitals, decline times went from 97 minutes in 2005 to 64 minutes in 2010. Hospitals with the greatest decline times were hospitals with at least 500 beds (median hospital time decline, 34 minutes), for-profit hospitals (38 minutes) and hospitals in the East-South-Central (40 minutes) and Mid-Atlantic census regions (35 minutes), according to the study.
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Based on this analysis of the CMS database, it would appear that national initiatives have been successful in reducing time delay to treatment of STEMI with primary PCI. Although the authors acknowledge changes in the methodology for measure of door-to-balloon, which occurred over time, it is noteworthy that the most dramatic reduction in door-to-balloon time occurred between 2006 and 2007 in concert with the allowance for multiple exclusions from reporting. These exclusions have been both nonclinical (as noted) and clinical (difficult arterial access; difficult coronary anatomy, etc), and the relative contribution of exclusions vs. process improvement cannot be exactly be determined.
Finally, exclusions from analysis, which were arbitrarily chosen by the authors (times >6 hours to capture patients undergoing primary PCI), have been added to the exclusions from reporting. Although logical, these exclusions from analysis may have conveniently eliminated important outliers. Thus, in the context of acknowledging both exclusions in reporting and analysis, these data suggest significant process improvement on a national basis. It would be of interest to compare this experience in the US with door-to-balloon times in other countries during a similar timeframe.
– Dean J. Kereiakes, MD
Cardiology
Today Intervention Editorial Board member
Disclosure: Dr.
Kereiakes reports no relevant financial disclosures.