Fast Care for Heart Attack Victims

The ongoing history of quality improvement in medical care in one of great theories and hypotheses which seldom seem to pan out in ultimate health outcomes.  A study in the New England Journal of Medicine deals with one such effort.   (NEJM Article)   A heart attack is typically due to constricted blood flow within the heart.  For a victim, getting to a setting where the affected artery can be opened more fully may be critical.  Therefore, many quality improvement programs have set a goal of a “door to balloon” time of less than 90 minutes.  Pay-for-performance and quality reporting programs frequently use this measure.  A large consortium of health systems provided the data used in the study from a registry, with a total of over 95,000 patients examined for the time period 2005-09.  Average door-to-balloon time decreased from 83 minutes in 2005-06 to 67 minutes in 2008-09, demonstrating the effect of the quality improvement programs.  The in-hospital mortality rate, however, barely budged, from 4.8% to 4.7%, a non-significant change.  Over 80% of patients were getting to the hospital in less than 90 minutes, but there mortality was unchanged.  Getting to the hospital in less than 90 minutes was clearly associated with lower mortality, but getting more patients there faster did not change overall mortality.  It may be that simply getting someone to the hospital faster isn’t the major factor in survival, other circumstances may be more important.  In any event, all the effort and money spent on this goal may not be getting the best bang for the buck.