ACC/AHA 2008 Statement on Performance Measurement and Reperfusion Therapy

The ACC/AHA 2008 Statement on Performance Measurement and Reperfusion Therapy was published on 11/10/08.

Here are some highlights (from the prehospital perspective) with comments:

“Acute reperfusion therapy, either with fibrinolytic therapy or percutaneous coronary intervention (PCI), is one of the most important treatments for patients with ST-segment elevation myocardial infarction (STEMI)…The timeliness of reperfusion therapy is of central importance, because the benefits of therapy diminish rapidly with delays in treatment.”

How rapidly? Consider this graph from Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996;348:771-775.


As you can see, with fibrinolytic therapy, the highest benefit is in the first hour. After 3 hours, the benefit drops off rapidly.

How important is prompt, expertly performed PCI? Consider this graph from Time to Treatment in Primary Percutaneous Coronary Intervention. N Engl J Med 2007;357:1631-1638.

As you can see, there is a significant increase in mortality for every 15 minutes of delay past 90 minutes.

“Thus, ACC/AHA guidelines recommend that fibrinolysis be provided within 30 minutes of first medical system contact and that primary PCI be provided within 90 minutes of first medical system contact for patients presenting with STEMI…”

That only makes sense. The ideal situation would be to measure from the time of symptom onset, but considering the average patient delay and the difficulty in pinpointing the exact moment of symptom onset, “time from discovery” is the most logical option.

“Beginning in 2004, the ACC/AHA STEMI guideline recommendations for both fibrinolysis and primary PCI recommend that patients receive therapy within a limited time from first medical system contact rather than from the time of presentation at an acute care facility.”

It’s almost 2009, so we’re coming up on 5 years since the 2004 guidelines came out. We should have made some serious progress toward measuring EMS-to-balloon (E2B) times, right?

Wrong.

“However, the current time-to-reperfusion measures reported by CMS and the Joint Commission and those endorsed by the ACC/AHA use the time of hospital presentation as the ‘start time.'”

I’m confused. Why the discrepancy?

“The time of hospital presentation at a healthcare institution has been used as the index time for several reasons. Practically, systematic approaches to collecting data on the time of first system contact have not been assessed or validated, whereas the time of presentation at an institution is routinely available in records.”

What could be simpler than looking at the EMS run sheet? I’m trying to be polite here, but what would the authors consider “validation” that EMS times are accurate?

“Furthermore, the appropriate definition of first medical system contact (eg, emergency medical services system activation versus time of first in-field ECG) is a topic of substantial debate.”

Interesting that no footnotes appear after this comment. Questions? Sure. But substantial debate? If you’re that worried about it, capture both time stamps.

“The use of time of presentation, the standard that has been used in previous measures, also provides consistency across time.”

All you have to do is capture the arrival time at the hospital. Then you’re free to continue your apples-to-apples comparisons. In fact, you could even measure the in-hospital impact of the out-of-hospital 12 lead ECG.

“Finally, issues of accountability with the time of first system contact are substantially more complicated than those surrounding the current reperfusion measures. Specifically, because current public reporting efforts focus on institutions rather than systems, measures that include the time from first system contact could potentially penalize institutions for issues beyond their control.”

If the current public reporting efforts focus on institutions and not systems, then how could they be punished? According to Dr. Alice Jacobs, non-PCI hospitals are already being punished by Medicare when they lose STEMI patients to hospitals capable of primary PCI.

Show me the hospitals that have tried to work with their local EMS systems and were frustrated by a complete lack of cooperation. I’m thinking they’re few and far between. From what I’ve seen, EMS wants to be engaged.

“The work group acknowledges, however, that the goal of evolution toward measuring the time of first system contact to reperfusion is appropriate for several reasons.”

The evolution toward measuring the time of first system contact, which the guidelines recommended in 2004? How many more years need to go by?

“First, with evolving health information technology, determining the time of first system contact is likely to become easier and more consistent.”

Because EMS hasn’t been documenting our call received time, arrival time, and so on, until recently?

“Second, the measures should remain consistent with guidelines whenever possible, presuming that practical barriers can be overcome.”

Does this really need to be verbalized?

“Finally, as systems of care to provide reperfusion proliferate, an understanding of the performance of these systems becomes increasingly important.”

Then get with the times! (No pun intended).

“Measuring the performance of systems is likely to foster the collaboration among multiple systems, including emergency medical services, that is necessary to ensure optimal quality of care.”

Exactly. So…?

“Although the work group agrees that performance measurement should migrate toward an approach of using the time of first system contact, it currently advocates the development of such measurement for quality-improvement purposes rather than for public reporting, with an explicit goal of addressing the issues described above as part of the implementation process. Such implementation testing would lay the foundation for the use of measures of time from first system contact to reperfusion as measures for the purposes of public accountability.”

EMS-to-balloon (E2B) is an idea whose time has come. Hopefully the success of those STEMI systems that are already following the guidelines will prove once and for all that it can be done.

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