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A new analysis from the
The most comprehensive outcomes-based quality improvement program in the
“This study shows that as a country, we do a good job in treating patients with heart attack,” said John S. Rumsfeld, M.D., Ph.D., chief science officer and chair of the NCDR and acting national director of cardiology for the Veterans Affairs Health Administration. “More patients with heart attacks qualify for urgent angioplasty and stenting, and they are getting it quicker. There have also been improvements in giving recommended medications to heart attack patients—many of which reduce the risk of death and long-term complications.”
Equally impressive are the results for coronary angioplasty and stenting. These procedures, which fall under the umbrella term percutaneous coronary intervention (PCI), involve threading a slender tube into the arteries of the heart, expanding a tiny balloon to widen the artery and, usually, leaving an expandable metal stent in place to hold the artery open.
“We’re seeing lower complication rates with PCI, despite greater complexity in both the types of patients and the lesions,” said Matthew T. Roe, M.D., M.H.S., associate professor of medicine at
For the study, researchers drew from two large NCDR registry programs. To characterize recent trends in treatment and outcomes of heart attack, they analyzed data from the ACTION Registry®–GWTG™. The NCDR ACTION Registry-GWTG is a partnership between the ACC and the American Heart Association and includes data on the hospital care of patients with two types of heart attack known as STEMI and NSTEMI. The resulting study group consisted of all 131,980 patients treated for a heart attack at approximately 250 participating hospitals from January 2007 through June 2009.
The data analysis showed significant improvements in several key aspects of heart attack care, including:
- Increase from 90.8 percent to 93.8 percent in the use of treatments to restore blood flow to the heart in patients with STEMI heart attacks.
- Increase from 64.5 percent to 88 percent in the number of patients with STEMI heart attacks treated with PCI within 90 minutes of arriving at the hospital—a key quality benchmark.
- Improvement from 89.6 percent to 92.3 percent in overall performance scores that measure timeliness and appropriateness of therapy for STEMI heart attacks.
- Improvement in achieving correct dosing of several types of “blood thinners” among NSTEMI patients.
- Reduction from 6.2 percent to 5.5 percent in risk-adjusted hospital death rates among STEMI patients and from 4.3 percent to 3.9 percent among NSTEMI patients.
- Improvement in prescribing guidelines-recommended medications, including aspirin, clopidogrel, statins, beta blockers and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, as well as in counseling patients to stop smoking and referring patients to cardiac rehabilitation.
Patients are also taking important steps toward improving heart attack care by heeding the warning signs of heart attack, the data reveal. The time from the beginning of heart attack symptoms to the patient’s arrival at the hospital dropped significantly during the study period, from 1.7 hours to 1.5 hours, on average.
“Patients are coming to the hospital sooner,” Dr. Rumsfeld said. “That shows a greater awareness by the public that if you have unexplained chest pain or shortness of breath, you need to get to the hospital quickly. The sooner you get treatment for a heart attack, the better your chances of survival and the less likely you are to experience long-term complications like heart failure.”
To evaluate PCI trends, investigators analyzed data from the NCDR CathPCI Registry® database, which contains hospital data on diagnostic cardiac catheterization and PCI. It is a partnership between the ACC and the Society for Cardiovascular Angiography and Interventions. The resulting PCI study group consisted of all 1,708,247 patients who had PCI from January 2005 through June 2009. During that time, participating hospitals grew from 436 to 959.
The data analysis revealed several notable trends, including:
- Increase in procedural complexity, including treatment of significantly more patients with challenging “type C” lesions.
- Reduction in complications related to bleeding or injury to the arteries used for passing tubes to the heart.
- Changes in the use of medications designed to prevent unwanted blood clots, reflecting the results of recent clinical trials and recommendations from new clinical practice guidelines.
- Reduction in the overall use of drug-eluting stents, partially balanced by increased use of new types of drug-eluting stents.
In addition to its encouraging findings, the analysis also highlights specific areas in need of improvement and identifies targets for future research, particularly those aimed at reducing the bleeding risk associated with even the best therapies.
Moreover, the analysis highlights the value of clinical registries themselves and the unique information they provide. Insurance databases document how many patients had a particular diagnosis or procedure, while randomized clinical trials test therapies under tightly controlled circumstances and in narrowly defined groups of patients. But the information from the NCDR documents the cardiovascular treatments average patients receive every day, and how those treatments affect their health. In short, it helps doctors give better cardiovascular care in daily practice.
“This is direct clinical data from doctors and hospitals themselves on which patients got which treatments and how they did,” Dr. Rumsfeld said. “If you want to actually understand the risk of a given patient and match the best treatment to their situation, you need real clinical data.”
The NCDR also helps hospitals and cardiologists to achieve the highest quality of care, by allowing them to compare their treatments and clinical outcomes against those of similar volume and size across the nation. Patients who understand the value of clinical registries can be advocates for improving healthcare quality in their communities.
“Educated consumers can stimulate improvements in their community,” Dr. Roe said. “If your hospital is not participating in the NCDR and other clinical registries, you should ask, ‘Why not? What are you doing to respond to and collect data that will allow you to take better care of your patients?’”
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