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Tracy Y. Wang, MD, MHS; Gregg C. Fonarow, MD; Adrian F. Hernandez, MD; Li Liang, PhD; Gray Ellrodt, MD; Brahmajee K. Nallamothu, MD, MPH; Bimal R. Shah, MD, MBA; Christopher P. Cannon, MD; Eric D. Peterson, MD, MPH

Arch Intern Med. 2009;169(15):1411-1419.

Background  Recent initiatives have focused on reducing door-to-balloon (DTB) times among patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. However, DTB time is only one of several important AMI care processes. It is unclear whether quality efforts targeted to a single process will facilitate concomitant improvement in other quality measures and outcomes.

Methods  This study examined 101 hospitals (43 678 patients with AMI) in the Get With the Guidelines program. For each hospital, DTB time improvement from 2005 to 2007 was correlated with changes in composite Centers for Medicare and Medicaid Services/Joint Commission on Accreditation of Healthcare Organizations (CMS/JCAHO) core measure performance and in-hospital mortality.

Results  Between 2005 and 2007, hospital geometric mean DTB time decreased from 101 to 87 minutes (P < .001). Mean overall hospital composite CMS/JCAHO core measure performance increased from 93.4% to 96.4% (P < .001), and mortality rates were 5.1% and 4.7% (P = .09) in the early and late periods, respectively. Improvement in hospital DTB time, however, was not significantly correlated with changes in composite quality performance (r = –0.06; P = .55) or with in-hospital mortality (r = 0.06; P = .58). After adjustment for patient mix, hospitals with the most improvement in DTB time did not have significantly greater improvements in either CMS/JCAHO measure performance or mortality.

Conclusions  Within the Get With the Guidelines program, DTB times decreased significantly over time. However, there was minimal correlation between DTB time improvement and changes in other quality measures or mortality. These results emphasize the important need for comprehensive acute myocardial infarction quality-improvement efforts, rather than focusing on single process measures.

Author Affiliations: Departments of Medicine/Cardiology, Duke Clinical Research Institute, Durham, North Carolina (Drs Wang, Hernandez, Liang, Shah, and Peterson); University of California, Los Angeles (Dr Fonarow); Berkshire Health Systems, Pittsfield, Massachusetts (Dr Ellrodt); University of Michigan Health System, Ann Arbor (Dr Nallamothu); and Brigham and Women's Hospital, Boston, Massachusetts (Dr Cannon).

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