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Objectives This study sought to determine the range and prevalence of practices being implemented by hospitals to reduce 30-day readmissions of patients with heart failure or acute myocardial infarction (AMI). Background Readmissions of patients with heart failure or AMI are both common and costly; however, evidence on strategies adopted by hospitals to reduce readmission rates is limited. Methods We used a Web-based survey to conduct a cross-sectional study of hospitals' reported use of specific practices to reduce readmissions for patients with heart failure or AMI. We contacted all hospitals enrolled in the Hospital to Home (H2H) quality improvement initiative as of July 2010. Of 594 hospitals, 537 completed the survey (response rate of 90.4%). We used standard frequency analysis to describe the prevalence of key hospital practices in the areas of: 1) quality improvement resources and performance monitoring; 2) medication management efforts; and 3) discharge and follow-up processes. Results Nearly 90% of hospitals agreed or strongly agreed that they had a written objective of reducing preventable readmission for patients with heart failure or AMI. More hospitals reported having quality improvement teams to reduce preventable readmissions for patients with heart failure (87%) than for patients with AMI (54%). Less than one-half (49.3%) of hospitals had partnered with community physicians and only 23.5% had partnered with local hospitals to manage patients at high risk for readmissions. Inpatient and outpatient prescription records were electronically linked usually or always in 28.9% of hospitals, and the discharge summary was always sent directly to the patient's primary medical doctor in only 25.5% of hospitals. On average, hospitals used 4.8 of 10 key practices; Conclusions Although most hospitals have a written objective of reducing preventable readmissions of patients with heart failure or AMI, the implementation of recommended practices varied widely. More evidence establishing the effectiveness of various practices is needed.

ObjectivesWe sought to determine the effect of door-to-balloon time on mortality for patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).BackgroundStudies have found conflicting results regarding this relationship.MethodsWe conducted a cohort study of 29,222 STEMI patients treated with PCI within 6 h of presentation at 395 hospitals that participated in the National Registry of Myocardial Infarction (NRMI)-3 and -4 from 1999 to 2002. We used hierarchical models to evaluate the effect of door-to-balloon time on in-hospital mortality adjusted for patient characteristics in the entire cohort and in different subgroups of patients based on symptom onset-to-door time and baseline risk status.ResultsLonger door-to-balloon time was associated with increased in-hospital mortality (mortality rate of 3.0%, 4.2%, 5.7%, and 7.4% for door-to-balloon times of ≤90 min, 91 to 120 min, 121 to 150 min, and >150 min, respectively; p for trend 90 min had increased mortality (odds ratio 1.42; 95% confidence interval [CI] 1.24 to 1.62) compared with those who had door-to-balloon time ≤90 min. In subgroup analyses, increasing mortality with increasing door-to-balloon time was seen regardless of symptom onset-to-door time (≤1 h, >1 to 2 h, >2 h) and regardless of the presence or absence of high-risk factors.ConclusionsTime to primary PCI is strongly associated with mortality risk and is important regardless of time from symptom onset to presentation and regardless of baseline risk of mortality. Efforts to shorten door-to-balloon time should apply to all patients.

Objectives The aim of this study was to determine the use of pre-hospital electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing reperfusion therapy, and evaluate the effect of pre-hospital ECG on door-to-reperfusion times. Background Although national guidelines recommend the use of pre-hospital ECG, there is limited contemporary information about its current use and effectiveness. Methods Using data from the National Registry of Myocardial Infarction-4, we studied patients with STEMI or left bundle branch block who received acute reperfusion with either fibrinolytic therapy (n = 35,370) or primary percutaneous coronary intervention (PCI) (n = 21,277) within 6 h of admission. We determined the prevalence of pre-hospital ECG use, evaluated the association between pre-hospital ECG and door-to-reperfusion time, and estimated the incremental reduction in time to reperfusion using hierarchical models to adjust for differences in patient and hospital characteristics. Results A pre-hospital ECG was performed in 4.5% of the fibrinolytic therapy cohort and in 8.0% of the PCI cohort. After adjusting for patient and hospital characteristics, the use of pre-hospital ECG was associated with a significantly shorter geometric mean door-to-drug time: 24.6 min (95% confidence interval [CI]: 23.7 to 25.5) vs. 34.7 min (95% CI: 34.2 to 35.3; p Conclusions The national use of pre-hospital ECG to diagnose and facilitate the treatment of STEMI remains low. When used, however, pre-hospital ECG is associated with a significantly shorter time to reperfusion.

OBJECTIVES The purpose of this study was to analyze recent trends in door-to-reperfusion time and to identify hospital characteristics associated with improved performance. BACKGROUND Rapid reperfusion improves survival for patients with acute ST-segment elevation myocardial infarction (STEMI). METHODS In this retrospective observational study from the National Registry of Myocardial Infarction (NRMI)-3 and -4, between 1999 and 2002, we analyzed door-to-needle and door-to-balloon times in patients admitted with STEMI and receiving fibrinolytic therapy (n = 68,439 patients in 1,015 hospitals) or percutaneous coronary intervention (n = 33,647 patients in 421 hospitals) within 6 h of hospital arrival. RESULTS In 1999, only 46% of the patients in the fibrinolytic therapy cohort were treated within the recommended 30-min door-to-needle time; only 35% of the patients in the percutaneous coronary intervention cohort were treated within the recommended 90-min door-to-balloon time. Improvement in these times to reperfusion over the four-year study period was not statistically significant (door-to-needle: -0.01 min/year, 95% confidence interval [CI] -0.24 to +0.23, p > 0.9; door-to-balloon: -0.57 min/year, 95% CI -1.24 to +0.10, p = 0.09). Only 33% (337 of 1,015) of hospitals improved door-to-needle time by more than one min/year, and 26% (110 of 421) improved door-to-balloon time by more than three min/year. No hospital characteristic was significantly associated with improvement in door-to-needle time. Only high annual percutaneous coronary intervention volume and location in New England were significantly associated with greater improvement in door-to-balloon time. CONCLUSIONS Fewer than one-half of patients with STEMI receive reperfusion in the recommended door-to-needle or door-to-balloon time, and mean time to reperfusion has not decreased significantly in recent years. Relatively few hospitals have shown substantial improvement.

Objectives We sought to recommend an approach for minimizing preventable delays in door-to-balloon time on the basis of experiences in top-performing hospitals nationally. Background Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity; however, door-to-balloon times often exceed the 90-min guideline set forth by the American College of Cardiology (ACC) and the American Heart Association (AHA). Methods We conducted a qualitative study using in-depth interviews (n = 122) of hospital staff at hospitals (n = 11) selected as top performers based on data from the National Registry of Myocardial Infarction from January 2001 to December 2002. We used the constant comparative method of qualitative data analysis to synthesize best practices across the hospitals. Results Top performers were those with median door-to-balloon times of ≤90 min for their most recent 50 PCI cases through December 2002 and the greatest improvement in median door-to-balloon times during the preceding four-year period 1999 to 2002. Several critical innovations are described, including use of pre-hospital electrocardiograms (ECGs) to activate the catheterization laboratory, allowing emergency physicians to activate the catheterization laboratory, and substantial interdisciplinary collaboration throughout the process. In the ideal approach, door-to-balloon time is 60 min for patients transported by paramedics with a pre-hospital ECG and 80 min for patients who arrive without paramedic transport and a pre-hospital ECG. Conclusions Hospitals can achieve the recommended ACC/AHA guidelines for door-to-balloon time with specific process design efforts. However, the recommended best practices involve extensive interdisciplinary collaboration and will likely require explicit strategies for overcoming barriers to organizational change.

Implantable Cardioverter-Defibrillators (ICDs) reduce sudden cardiac death. However, about 25% of patients with ICDs are shocked in the last month of life(1), and these shocks may cause frightening and painful deaths. Little is known about how physicians’ attitudes influence their decisions to discuss ICD deactivation with patients. We created a simple random sample of the American Medical Association Masterfile by choosing 100 physicians from each of four strata: electrophysiologists, cardiologists, geriatricians, and internists. Eligible clinicians had to be in active practice and had to have cared for at least one patient with an ICD. We mailed letters to all physicians introducing the study, and then followed up by telephone to administer the survey. Physicians who could not be contacted telephonically were mailed surveys, and a series of incentives were used to encourage participation. All surveys were anonymous. This project was exempt from review by the Mount Sinai School of Medicine IRB. We based the survey on our previous qualitative work.(2,3) The instrument included Likert scales (1 (strongly disagree) to 5 (strongly agree)) to determine physicians’ attitudes relating to ICD conversations (Table 1). Data were analyzed as both continuous and dichotomous variables. As the results of these analyses were similar, the Likert scales are reported as strongly agree or agree versus all others. For between group comparisons, the chi-square test was used; Fisher’s Exact test was used for smaller cell sizes. P-values reflect comparisons across the four groups. There was no difference in response patterns between phone and written surveys. ANOVA was used to evaluate the differences in age of respondents across the four groups. Significance levels for individual tests were not adjusted as the survey was based on qualitative data and the sample size was small thus making it unlikely that any observed association would be due to chance alone.(4) All calculations were performed using SAS v9.0 (Cary, NC). Table 1 Results of 5-point Likert scales to Determine Physicians’ Attitudes Relating to Care of Patients with ICDs Of the 400 physicians selected for the survey, 11 were deemed ineligible (7 were retired and 4 had never cared for a patient with an ICD) and 52 could not be located. Of the remaining 337 eligible physicians, 147 completed surveys, yielding a response rate among physicians who could be located of 44% (147/337). Electrophysiologists had a higher response rate (58%) compared with cardiologists (36%), internists (37%) and geriatricians (41%) (p=.013). Geriatricians tended to be older than cardiologists, electrophysiologists, or internists (mean age 54.1 years vs. 48.3, 49.0, and 48.1 respectively, p-value

To the Editor: Data on hospital performance in door-to-balloon (DTB) times for patients with ST-segment elevation myocardial infarction (STEMI) are now collected and reported by numerous organizations, including the Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and the

The purpose of this study was to determine if enrollment in the Door-to-Balloon (D2B) Alliance, a national quality campaign sponsored by the American College of Cardiology and 38 partner organizations, was associated with increased likelihood of patients who received primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) being treated within 90 min of hospital presentation.The D2B Alliance, launched in November 2006, sought to achieve the goal of having 75% of patients with STEMI treated within 90 min of hospital presentation.We conducted a longitudinal study of D2B times in 831 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, April 1, 2005, to March 31, 2008.By March 2008,75% of patients had D2B times ofor = 90 min, compared with only about one-half of patients with D2B times within 90 min in April 2005. Trends since the launch of the D2B Alliance showed that patients treated in hospitals enrolled in the D2B Alliance for at least 3 months were significantly more likely than patients treated in nonenrolled hospitals to have D2B times within 90 min, although the magnitude of the difference was modest (odds ratio: 1.16; 95% confidence interval: 1.07 to 1.27).The D2B Alliance reached its goal of 75% of patients with STEMI having D2B times within 90 min by 2008.

The aim of this study was to determine the use of pre-hospital electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing reperfusion therapy, and evaluate the effect of pre-hospital ECG on door-to-reperfusion times.Although national guidelines recommend the use of pre-hospital ECG, there is limited contemporary information about its current use and effectiveness.Using data from the National Registry of Myocardial Infarction-4, we studied patients with STEMI or left bundle branch block who received acute reperfusion with either fibrinolytic therapy (n = 35,370) or primary percutaneous coronary intervention (PCI) (n = 21,277) within 6 h of admission. We determined the prevalence of pre-hospital ECG use, evaluated the association between pre-hospital ECG and door-to-reperfusion time, and estimated the incremental reduction in time to reperfusion using hierarchical models to adjust for differences in patient and hospital characteristics.A pre-hospital ECG was performed in 4.5% of the fibrinolytic therapy cohort and in 8.0% of the PCI cohort. After adjusting for patient and hospital characteristics, the use of pre-hospital ECG was associated with a significantly shorter geometric mean door-to-drug time: 24.6 min (95% confidence interval [CI]: 23.7 to 25.5) vs. 34.7 min (95% CI: 34.2 to 35.3; p0.0001), and a significantly shorter geometric mean door-to-balloon time (94.0 min [95% CI: 91.8 to 96.3] vs. 110.3 min [95% CI: 108.7 to 112.0]; p0.0001).The national use of pre-hospital ECG to diagnose and facilitate the treatment of STEMI remains low. When used, however, pre-hospital ECG is associated with a significantly shorter time to reperfusion.

We sought to recommend an approach for minimizing preventable delays in door-to-balloon time on the basis of experiences in top-performing hospitals nationally.Prompt percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity; however, door-to-balloon times often exceed the 90-min guideline set forth by the American College of Cardiology (ACC) and the American Heart Association (AHA).We conducted a qualitative study using in-depth interviews (n = 122) of hospital staff at hospitals (n = 11) selected as top performers based on data from the National Registry of Myocardial Infarction from January 2001 to December 2002. We used the constant comparative method of qualitative data analysis to synthesize best practices across the hospitals.Top performers were those with median door-to-balloon times ofor =90 min for their most recent 50 PCI cases through December 2002 and the greatest improvement in median door-to-balloon times during the preceding four-year period 1999 to 2002. Several critical innovations are described, including use of pre-hospital electrocardiograms (ECGs) to activate the catheterization laboratory, allowing emergency physicians to activate the catheterization laboratory, and substantial interdisciplinary collaboration throughout the process. In the ideal approach, door-to-balloon time is 60 min for patients transported by paramedics with a pre-hospital ECG and 80 min for patients who arrive without paramedic transport and a pre-hospital ECG.Hospitals can achieve the recommended ACC/AHA guidelines for door-to-balloon time with specific process design efforts. However, the recommended best practices involve extensive interdisciplinary collaboration and will likely require explicit strategies for overcoming barriers to organizational change.