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Over a span of five years, the initiative to improve door-to-balloon time for people experiencing out-of-hospital myocardial infarction has resulted in significantly lower transport and treatment times, a nationwide analysis showed.

From 2005 to 2010, door-to-balloon time declined from a median of 96 minutes to 64 minutes, reported Harlan R. Krumholz, MD, from Yale University School of Medicine, and colleagues.

Moreover, there were corresponding increases in the percentage of patients who had times under 90 minutes (44.2% to 91.4%), as well as under 75 minutes (27.3% to 70.4%), according to the study published online in Circulation: Journal of the American Heart Association.

"These results show the profession at one of its finest moments," Krumholz told MedPage Today in an interview. "The research isn't top-down research. It's about trying to ferret out the secrets of success from those doing the best."

There were no financial incentives for the door-to-balloon initiative to go forward. It is about disseminating best patient practices, Krumholz noted.

"Over this five-year period, we've had this extraordinary change in practice. And now any American who has a heart attack that requires angioplasty can feel confident that he or she will be treated very quickly," he said.

A study in 2006 showed that only a third of patients received primary PCI within 90 minutes, and a third waited longer than two hours after arriving at the hospital (J Am Coll Cardiol 2006; 47: 45–51), but that same year Krumholz and colleagues reported that a handful of simple measures could substantially shorten that time interval.

This latest publication represents a culmination of those efforts, Krumholz said in an email.

First, the Centers for Medicare and Medicaid Services (CMS) began to publicly report the percent of patients treated within recommended times. Then, the American College of Cardiology and others launched the D2B Alliance, which advocated the "adoption of key strategies that had been shown to reduce delays based on a study funded by the National Heart, Lung, and Blood Institute." Finally, the American Heart Association launched Mission: Lifeline, another national initiative created to speed the care of STEMI patients.

Studies charting the success of D2B times following these initiatives were generally from registries, which represent a "selected sample" of U.S. hospitals, Krumholz and colleagues wrote.

"There has been no national assessment of the trends in D2B times, nor do we know whether improvements in D2B times were shared equally among patient and hospital groups," they said.

To fill in those gaps, they analyzed data reported by hospitals to CMS for inclusion in the time to PCI inpatient measure. During the study period, the number of patients was fairly constant, ranging between 48,977 and 53,682.

At baseline, slightly more than half of all patients were between the ages of 46 and 65, three-quarters were men, and 80% were white. These numbers did not vary significantly during the study period.

In 2005, 44.2% and 27.3% of patients had D2B times in under 90 and 75 minutes, respectively. In 2010, those numbers were 91.4% and 70.4%.

The investigators found a median drop in D2B time of 32 minutes during the time span (96 to 64 minutes), which represents a greater than 30% relative decline.

"This improvement, experienced across the country and across different types of hospitals, represents a remarkable elevation in practice that was achieved over a relatively short period of time and in the absence of financial incentive," researchers wrote.

They also said that these improvements were likely due to multiple factors, rather than one single overriding action, including:

• Published articles that identified strategies for improving door-to-balloon time
• National initiatives by various organizations
• Identifying "exceptional" performers and analyzing their methods
• CMS' emphasis on quality improvement in this area

Krumholz noted that each hospital had to find places to "shave minutes" off their D2B times. There generally wasn't one single area that could decrease D2B time by significant amounts of time.

He compared it to racing pit crews, who work tirelessly to cut mere seconds from every action during a pit stop.

Christopher White, president of the Society for Cardiovascular Angiography and Interventions (SCAI), told MedPage Today that these improvements could not have happened if the medical professions involved were practicing in silos.

"One of the major changes in practice was for cardiologists to allow EMTs or ED physicians to activate the cath lab before the cardiologist determined or confirmed the patient had an MI," White said. "That was a huge shift and very necessary for reducing door-to-balloon time."

While seconds can still be cut from existing D2B protocols, there is one area on which stakeholders will focus more attention going forward: transfer times for patients who must be transported to a PCI-capable hospital.

CMS is considering publicly reporting transfer times, Krumholz and colleagues said. "More importantly, current research shows that these times can be reduced through greater coordination between hospitals."

Limitations to the study included modifications to the CMS reporting process over the time period, which could have affected results.

From the American Heart Association:

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