Real World Health Care Blog

Tag Archives: cardiology

It’s Not Over Yet: Addressing Part Two of the Door-to-Balloon Time Initiative’s Success

ReillyJohn

John P. Reilly, M.D., FSCAI

From the very first sign of a heart attack, the clock starts ticking in the race to save a patient’s heart muscle and even his or her life.

Thanks to technology and finely tuned systems of heart attack care that are now available in communities throughout the United States, we are getting faster all the time.

But sometimes we still lose the race.

During a heart attack, the heart is deprived of oxygen. The longer the heart goes with too little oxygen, the more muscle is lost, often irreversibly. This is what doctors mean when we say, “Time is muscle.” How quickly a patient receives treatment once heart attack symptoms appear often determines if he or she will make a full recovery, suffer heart muscle damage, or die.

Door to Balloon Signaled Success, or Did It?

This is why, a decade ago, healthcare professionals across the country set out to reduce the time it takes to treat heart attack patients once they arrive at the hospital. Since stopping a heart attack often involves balloon angioplasty to reopen the blocked artery, the effort was called the Door-to-Balloon (D2B) Initiative. This effort has prevented or limited heart damage for countless patients.

The D2B initiative involved making the healthcare system more efficient, more responsive and more effective, starting from the moment a heart attack patient comes to the attention of an emergency medical responder (EMR) answering a 9-1-1 call or presenting in the emergency department.  When D2B began, it often took more than two hours from the time a heart attack patient arrived at the hospital until he or she received life-saving treatment to reopen a blocked artery.

Now, 90 percent of patients who enter hospital doors receive treatment in less than 90 minutes and many are treated within 60, 30, even 15 minutes. [1]

D2B is one of healthcare’s greatest success stories. But, according to a new study [2], reducing D2B times has not been enough to significantly reduce mortality rates among heart attack patients.

What Happens Before the Hospital Door?

There are two sides to the time equation. Unfortunately, the part of the equation that has not improved enough is how long it takes patients to get to the hospital once heart attack symptoms start. Most patients wait two or more hours after heart attack symptoms appear to seek medical help. [3] Many patients are taking too long to call 9-1-1, placing themselves at risk of suffering irreversible heart damage or death.

We must do for Symptom-to-Door (S2D) Time what we have done so successfully for D2B. Revamping a system of care outside the hospital, however, is much different and perhaps more difficult than revamping a system of care within the hospital.

There have been myriad heart attack awareness programs, including online public education programs like SecondsCount.org, for which I am an editor, aimed at helping people understand the risks of heart attack, how to recognize the symptoms and why responding promptly is essential.

We have made progress. An increasing number of people know that chest pain, shortness of breath, nausea, fatigue, dizziness, and pain in the jaw, back or arm are often the first signs of heart attack. While I see more people who identified their symptoms early on, there are also many who remain unaware, are in denial or are just confused. Every day, I see patients who thought their symptoms “weren’t that bad” or explain them away as indigestion or a virus. I also see the toll that lost time takes in hearts damaged and lives lost.

Only 60 percent of patients contact emergency medical responders when experiencing symptoms. About 40 percent arrive at our hospitals on their own. [4] That’s dangerous, whether the patient is driving him- or herself. Or, even if a friend or relative is driving, it still represents a lost opportunity for treatment to begin in the ambulance, or to alert the doctors in the emergency room that a heart attack patient is on the way in.

Let’s Save More Hearts and Lives

To get started, here are a few thoughts on how we might reduce S2D:

  • We need a concerted national effort to reduce S2D time that establishes consistent messages rather than myriad programs offering incomplete or inconsistent information.
  • We must improve regional and statewide systems of care to coordinate heart attack care to ensure everyone gets the most expeditious care.
  • We need to better inform the people who are most at risk for heart attack or other heart issues about what symptoms to look for and what to do if they develop.
  • And, of course, we must continue our educational efforts, helping everyone to understand that if they are concerned they may be having a heart attack, then they should call 9-1-1 without delay and without concern about looking foolish if their symptoms turn out to be something other than a heart attack.  The alternative – sitting at home while having a heart attack, with heart muscle dying as the minutes tick by – would be far worse.

We’ve had remarkable success in reducing D2B times. But it’s not enough. To save hearts and lives, we must take on the other side of the heart attack challenge.

We’ve done it once. We can do it again.

1. Bates ER, Jacobs AK. Time to Treatment in Patients with STEMI. N Engl J Med 2013;369:889-892.
2. Menees DS, Peterson ED, Wang Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med 2013;369:901-9.
3.  Life After a Heart Attack. National Heart, Lung, and Blood Institute.
4.  http://nypress.com/forty-percent-do-not-call-911-survival-rates-show-every-minute-matters/, http://www.nejm.org/doi/full/10.1056/NEJMp1308772

Does More Data = More Accurate Results?

Every year U.S. News & World Report comes out with its “Best Hospitals” rankings, and providers wear them like a badge of honor. No doubt the recognition is prestigious. But how many people know why hospitals are ranked as they are? We decided to dig a little deeper and break down the methodology behind the rankings. What we found might surprise you.

Paul DeMiglio

Paul DeMiglio

“Best Hospitals” scores top hospitals across 16 specialties, from Cancer to Urology. For 12 of the 16 specialties, the rankings are based on performance measurements in structure, process and outcomes. Rankings in the remaining four specialties are based on hospital reputation as determined by a physician survey.

The methodology has evolved since the list was first published in 1990, transitioning from a heavy reliance on the reputation of hospitals (based on surveys of medical specialists) to incorporating more hard data to determine which providers make the cut. In an effort to increase accuracy and develop more objective, higher scoring methods, U.S. News & World Report moved away from expert opinion as a major factor of its criteria. Reputation now comprises only 32.5% of the overall score, except for hospitals in the areas of ophthalmology, psychiatry, rehabilitation and rheumatology.

The clinical data now used as the primary basis to rank hospitals measure patient outcomes and processes of care, based on factors including mortality, nurse staffing and advanced technologies. Hospitals also have to meet specific minimums for patient volume and are immediately considered high performing if they have a specialty like cancer or cardiology, among many others.

The power in this report lies in the objectivity as well as the information sharing from multiple, well-respected health care organizations and databases that exist as treasure troves for comprehensive patient information. The continuum of survey strategy — structure, process and outcome — defines essentially every step of the patient experience, from diagnosis to treatment to outcome.

For decades, much of patient care revolved around anecdotal teachings and recommendations. Hospital choices for individuals with complicated conditions often occurred subjectively and by word-of-mouth from both patients as well as caregivers. The strength in the “Best Hospitals” study design lies in the breadth of specialties, objectivity, number of hospitals, as well as the reachability and understandability of the results to the general public.  As the number of survey variables continues to increase by virtue of an aging population and the emergence of newer diseases and a greater number of treatment options, survey criteria will evolve and may correlate patient cost to outcome.  In other words, how much health care bang does one get for the buck?

For a detailed overview of the methodology behind “U.S. News & World Report’s Best Hospitals,” click here.

Is this system for ranking hospitals as objective as it could be? Does making the qualification guidelines more data-driven increase the reliability of the outcomes?