Context: Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy. Objective: To determine th...Context: Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy. Objective: To determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality. Design, Setting, and Participants: Cohort study of 68 439 patients with ST-segment elevation myocardial infarction(STEMI) treated with fibrinolytic therapy and 33 647 treated with percutaneous coronary intervention(PCI) from 1999 through 2002. We classified patient hospital arrival period into regular hours(weekdays, 7 AM-5 PM) and off-hours(weekdays 5 PM-7 AM and weekends). Main Outcome Measures: Geometric mean door-to-drug time for fibrinolytic therapy and door-to-balloon time for PCI and all-cause in-hospital mortality. All outcomes were adjusted for patient and hospital characteristics. Results: Most fibrinolytic therapy(67.9%) and PCI patients(54.2%) were treated during off-hours. Door-to-drug times were slightly longer during off-hours(34.3 minutes) than regular hours(33.2 minutes; difference, 1.0 minute; 95%confidence interval[CI], 0.7-1.4; P< .001). In contrast, door-to-balloon times were substantially longer during off-hours(116.1 minutes) than regular hours(94.8 minutes; difference, 21.3 minutes; 95%CI, 20.5-22.2; P< .001). A lower percentage of patients met guideline recommended times for door-to-balloon during off-hours(25.7%) than regular hours(47%; P< .001). Door-to-balloon times exceeding 120 minutes occurred much more commonly during off-hours(41.5%) than regular hours(27.7%; P< .001). Longer off-hours door-to-balloon times were primarily due to a longer interval between obtaining the electrocardiogram and patient arrival at the catheterization laboratory(off-hours, 69.8 minutes vs regular hours, 49.1 minutes; P< .001). This pattern was consistent across all hospital subgroups examined. Furthermore, patients presenting during off-hours had significantly higher adjusted in-hospital mortality than patients presenting during regular hours(odds ratio, 1.07; 95%CI, 1.01-1.14; P=.02). Conclusions: Presentation during off-hours was common and was associated with substantially longer times to treatment for PCI but not for fibrinolytic therapy. To achieve the best outcomes, hospitals providing PCI during off-hours should commit to doing so in a timely manner.展开更多
Context: The Centers for Medicare &Medicaid Services(CMS) and the Joint Commission on Accreditation of Healthcare Organizations(JCAHO) measure and report quality process measures for acute myocardial infarction(AM...Context: The Centers for Medicare &Medicaid Services(CMS) and the Joint Commission on Accreditation of Healthcare Organizations(JCAHO) measure and report quality process measures for acute myocardial infarction(AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital’s outcomes can be made from its performance on publicly reported processes. Objective: To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates. Design, Setting, and Participants: We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction(NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data. Main Outcome Measures: Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older. Results: We found moderately strong correlations(correlation coefficients ≥0.40; P values< .001) for all pairwise comparisons between β-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures(correlation coefficients< 0.40; P values< .001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates(P values< .001) but together explained only 6.0%of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI. Conclusions: The publicly reported AMI process measures capture a small proportion of the variation in hospitals’risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.展开更多
文摘Context: Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy. Objective: To determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality. Design, Setting, and Participants: Cohort study of 68 439 patients with ST-segment elevation myocardial infarction(STEMI) treated with fibrinolytic therapy and 33 647 treated with percutaneous coronary intervention(PCI) from 1999 through 2002. We classified patient hospital arrival period into regular hours(weekdays, 7 AM-5 PM) and off-hours(weekdays 5 PM-7 AM and weekends). Main Outcome Measures: Geometric mean door-to-drug time for fibrinolytic therapy and door-to-balloon time for PCI and all-cause in-hospital mortality. All outcomes were adjusted for patient and hospital characteristics. Results: Most fibrinolytic therapy(67.9%) and PCI patients(54.2%) were treated during off-hours. Door-to-drug times were slightly longer during off-hours(34.3 minutes) than regular hours(33.2 minutes; difference, 1.0 minute; 95%confidence interval[CI], 0.7-1.4; P< .001). In contrast, door-to-balloon times were substantially longer during off-hours(116.1 minutes) than regular hours(94.8 minutes; difference, 21.3 minutes; 95%CI, 20.5-22.2; P< .001). A lower percentage of patients met guideline recommended times for door-to-balloon during off-hours(25.7%) than regular hours(47%; P< .001). Door-to-balloon times exceeding 120 minutes occurred much more commonly during off-hours(41.5%) than regular hours(27.7%; P< .001). Longer off-hours door-to-balloon times were primarily due to a longer interval between obtaining the electrocardiogram and patient arrival at the catheterization laboratory(off-hours, 69.8 minutes vs regular hours, 49.1 minutes; P< .001). This pattern was consistent across all hospital subgroups examined. Furthermore, patients presenting during off-hours had significantly higher adjusted in-hospital mortality than patients presenting during regular hours(odds ratio, 1.07; 95%CI, 1.01-1.14; P=.02). Conclusions: Presentation during off-hours was common and was associated with substantially longer times to treatment for PCI but not for fibrinolytic therapy. To achieve the best outcomes, hospitals providing PCI during off-hours should commit to doing so in a timely manner.
文摘Context: The Centers for Medicare &Medicaid Services(CMS) and the Joint Commission on Accreditation of Healthcare Organizations(JCAHO) measure and report quality process measures for acute myocardial infarction(AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital’s outcomes can be made from its performance on publicly reported processes. Objective: To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates. Design, Setting, and Participants: We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction(NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data. Main Outcome Measures: Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older. Results: We found moderately strong correlations(correlation coefficients ≥0.40; P values< .001) for all pairwise comparisons between β-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures(correlation coefficients< 0.40; P values< .001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates(P values< .001) but together explained only 6.0%of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI. Conclusions: The publicly reported AMI process measures capture a small proportion of the variation in hospitals’risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.
