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Door-to-balloon time not associated with in-hospital mortality
US door-to-balloon times have improved for patients undergoing primary PCI, but there has been no change in in-hospital mortality, according to the results of a new study.
“These data suggest that additional strategies are needed to reduce in-hospital mortality in this population,” Daniel S. Menees, MD, and colleagues wrote.
Menees, of the University of Michigan, and colleagues assessed whether decreasing door-to-balloon times, which have become a focus of quality-improvement initiatives and are tied to reimbursement from CMS, have been accompanied by decreasing mortality in the PCI population.
The researchers analyzed 96,738 admissions for patients undergoing primary PCI for ST segment elevation MI (28% women; mean age, 60.8 years; mean ejection fraction, 46.8%). Using data from 515 hospitals in the CathPCI registry, they examined annual trends in door-to-balloon times and in-hospital mortality rates from July 2005 to June 2009. They also assessed 30-day mortality rates for a subset of 26,202 patients included in a linked Medicare data set. Patients with a door-to-balloon time of more than 3 hours were excluded “in an effort to include the patients who had the most to gain with respect to myocardial salvage,” Menees and colleagues wrote. Also excluded were patients undergoing nonemergency PCI and those transferred from another facility.
Median door-to-balloon times declined from 83 minutes in the 12-month period from July 2005 to June 2006 to 67 minutes in the 12-month period from July 2008 to June 2009 (P<.001). The rate of door-to-balloon times ≤90 minutes rose from 59.7% in the first year to 83.1% in the last year (P<.001).
However, unadjusted in-hospital mortality rates did not change (4.8% in the first year vs. 4.7% in the last year; P=0.43 for trend). Risk-adjusted in-hospital mortality rates also did not change (5% in the first year vs. 4.7% in the last year; P=.34).
In the subset of patients from the Medicare data set for whom follow-up information was available, median door-to-balloon times decreased from 88 minutes in 2005 to 68 minutes in 2009 (P<.001), but unadjusted 30-day mortality rates did not change (9.7% in 2005 vs. 9.8% in 2009; P=.64).
“Our data suggest that further efforts to reduce door-to-balloon time may not reduce mortality,” Menees and colleagues wrote. “We therefore conclude that additional factors will probably be needed to accomplish this goal. Door-to-balloon time is one component of total ischemic time; as door-to-balloon time is reduced, it becomes a smaller fraction of total ischemic time, making the time before arrival at a hospital a more important factor. Therefore, efforts with potential to improve outcomes may include increasing patients’ awareness of symptoms, reducing the interval from the time of symptom onset to treatment, and shortening the transfer time between medical facilities.”
Disclosure: See the full study for a list of the researchers’ relevant financial disclosures.