Perspective:

The ability to exclude patients from a performance measure is critical to ensure that assessments of quality across institutions or providers are appropriately comparing ‘apples’ to ‘apples.’ However, the use of potentially ‘subjective’ criteria for exclusion is worrisome. Such criteria can be easily gamed so that the exclusions are applied not only to tough cases, but to ‘failures’ where better care could and should have been delivered. This interesting paper by McCabe and colleagues looks at this issue from the perspective of DTB time, which has emerged as an important performance measure for primary PCI in ST-segment elevation myocardial infarction (STEMI) patients. Their findings suggest that the rates of CMS-excluded patients have risen significantly over time across three hospitals in Massachusetts. Furthermore, they found that these patients are fundamentally different and at a typically higher risk. These results are only from three hospitals in a single state, so we do need to keep them in perspective. Nevertheless, I believe this paper and its findings have important policy implications. The authors mention many of them in their excellent discussion. Mainly, what should be the role of DTB time in reimbursement for Value-Based Purchasing programs, and what are the next steps that need to be considered for improving care in STEMI patients? Are there new measures that we should be moving toward as DTB times have improved nationally? Should these measures include more ‘systems-based’ metrics that evaluate both prehospital and hospital care, like symptom-onset-to-reperfusion? These questions need to be tackled as there remains a subset of STEMI patients at high risk for complications and care for these patients may be variable.