Improving Quality of Care For Heart Attack, A Statewide Program

Implementation of a heart attack care program in North Carolina to increase the rate of coronary reperfusion (restoring blood flow to the heart muscle) for heart attack significantly improved the quality of care these patients received, according to a study in JAMA being released early online to coincide with its release at the American Heart Association's annual meeting. The study will be published in the November 28 print issue of JAMA.

ST-segment elevation myocardial infarction (STEMI; a certain pattern on an electrocardiogram during a heart attack) is a potentially lethal condition for which specific therapies, administered rapidly, can reduce the risk of death and illness. Despite more than two decades of clinical trial evidence demonstrating significant benefits from prompt coronary reperfusion, registries continue to show that most patients are still treated too slowly for reperfusion to be of maximal benefit, and many are not treated at all, according to background information in the article. The reasons for this are largely related to systematic barriers.

James G. Jollis, M.D., of Duke University, Durham, N.C., and colleagues conducted a study to determine if establishment of a coordinated statewide system of reperfusion therapy for STEMI (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments [RACE] study), as exists for trauma, would overcome systematic barriers and both decrease delays in administering reperfusion therapy and increase the frequency with which reperfusion was provided to eligible patients. The researchers focused on the coordination of each aspect of care from the initial emergency medical response to reperfusion itself, whether is was fibrinolytic therapy (medication for dissolving blood clots) or primary percutaneous coronary intervention (PCI; procedures such as balloon angioplasty or stent placement used to open blocked coronary arteries), whichever was most appropriate for a given setting.

The study included 65 hospitals and associated emergency medical systems (10 PCI hospitals and 55 non-PCI hospitals) in five regions in North Carolina, and 1,164 patients with STEMI (579 pre-intervention, 585 post-intervention) eligible for reperfusion who were treated at PCI hospitals; and 925 patients with STEMI (518 pre-intervention, 407 post-intervention) who were treated at non-PCI hospitals. The authors examined the reperfusion times and rates three months before (July - September 2005) and three months after (January - March 2007) a year-long implementation.

Among patients presenting to PCI hospitals who underwent primary PCI, the proportion with first door-to-device times less than 90 minutes increased from 57 percent to 72 percent with a decrease in median (midpoint) time from 85 to 74 minutes. For patients transferred from a non-PCI hospital to another hospital for primary PCI, median time from first door-to-device declined from 165 minutes to 128 minutes. For patients presenting to the 55 non-PCI hospitals, median door-in to door-out times decreased from 120 minutes to 71 minutes. Reperfusion times also improved for door-to-needle times in non-PCI hospitals (35 to 29 minutes).

For patients treated at or transferred to PCI hospitals, clinical outcomes including death, cardiac arrest, and cardiogenic shock did not significantly change following the intervention, although the study was not designed to directly assess these outcomes.

"We have demonstrated that a statewide program focused on the development of regional systems for STEMI reperfusion can significantly improve quality of care of heart attack patients. Further research is needed to ensure that this and other programs that demonstrate improvement in application of reperfusion therapies lead to reduced mortality and morbidity from acute myocardial infarction," the authors conclude.