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Amanda Jekowsky , American College of
Cardiology, 202-375-6645, ajekowsk@acc.org
November
10, 2008
Time to Reperfusion Performance Measures
Please note: The ACC/AHA 2008 Task Force on
Performance Measures’ Statement on Performance Measurement
and Reperfusion Therapy will webpost on Monday, November 10
at 2 pm ET. The statement clarifies key issues in the measurement
of reperfusion therapy for patients with ST-segment elevation
myocardial infarction.
The use of reperfusion therapy, drugs or procedures that restore
blood flow to the heart during a heart attack, is one of the
most powerful interventions available to improve a patient’s
likelihood of survival. While the appropriate and timely use
of reperfusion therapy has improved substantially over the
past decade, significant gaps in the quality of this important
process of care persist. Proper measurement is critical to
the assessment of hospital and health system performance and
to identify targets for quality improvement.
This document provides a perspective on the evolution of the
current measures, a justification for the approach and suggests
additional measures needed to provide a more comprehensive
assessment of care.
The document acknowledges the remaining controversy about
the inclusion and exclusion criteria for these measures, and
the determination of when measurement stops. Considerations
in choosing how to construct the measure are discussed and
specific recommendations are made to strengthen the current
approach.
The major points addressed in this document include:
- Acute reperfusion therapy—either with fibrinolytic
therapy or percutaneous coronary intervention—is one
of the most important treatments for patients with ST-segment
elevation myocardial infarction (STEMI)
- American College of Cardiology (ACC)/American Heart Association
(AHA) guidelines recommend that fibrinolysis be provided
within 30 minutes of first medical system contact and that
primary percutaneous coronary intervention (PCI) be provided
within 90 minutes of first medical system contact for patients
presenting with STEMI.
- The goals of the reperfusion performance measures are
to provide a quantitative assessment of this important process
of care; introduce accountability for performance in providing
timely reperfusion; to improve the quality of care; and
to reduce adverse outcomes of patients with STEMI.
- The workgroup supports current efforts by CMS and The
Joint Commission to simplify the current ECG interpretation
data elements to the extent possible, acknowledging that
it must provide adequate guidance to non-clinical abstractors
in identifying possible candidates for acute reperfusion.
- An additional measure that includes patients who are
transferred from one hospital to another for the purpose
of receiving reperfusion should be developed and implemented.
- An exclusion that accounts for patient-centered reasons
for delaying reperfusion therapy is clinically necessary.
- Systems providing reperfusion therapy should synchronize
all devices (e.g. ECG machines and electronic catheterization
lab documentation systems) involved in establishing time
landmarks in the reperfusion measures to a consistent external
standard (e.g. satellite synchronization with atomic clocks).
- After consideration of the relative benefits and limitations
of the various approaches, the workgroup supports a measure
that focuses upon the time of first device use rather than
the time of restoration of flow or the time of other “upstream”
events (e.g. time to first angiography).
- The time to PCI for patients who are transferred for
reperfusion should be reported separately from those who
are not transferred.
- In cases where a patient has a contraindication to reperfusion
therapy, the clinician does not have the option of considering
fibrinolysis rather than transfer, even if the transfer
will be delayed. Thus, reporting of the time to PCI in patients
who are transferred should be stratified by the presence
or absence of contraindications to fibrinolytic therapy.
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cardiovascular care and disease prevention. The College is
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credential Fellow of the American College of Cardiology upon
physicians who meet its stringent qualifications. The College
is a leader in the formulation of health policy, standards
and guidelines, and is a staunch supporter of cardiovascular
research. The ACC provides professional education and operates
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quality care. More information about the association is available
online at www.acc.org .
The American College of Cardiology (ACC) provides these news
reports of clinical studies published in the Journal of
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