Reporting Trends and Outcomes in ST-Segment–Elevation Myocardial Infarction National Hospital Quality Assessment Programs

Study Questions:

How frequently are patients who undergo primary percutaneous coronary intervention (PCI) excluded from Centers for Medicare & Medicaid Services (CMS) reporting on door-to-balloon (DTB) time, and are the remaining patients an adequate surrogate population for the total primary PCI cohort?


DTB time is a national quality performance metric for primary PCI endorsed by CMS and other organizations. The authors assessed all primary PCI-eligible patients at three Massachusetts hospitals (Brigham & Women’s, Massachusetts General, and North Shore Medical Center) and evaluated patients for CMS reporting status. The primary endpoint of the study was rates of CMS reporting exclusion. Key secondary endpoints included differences in patient characteristics, DTB times, and 1-year mortality rates among patients excluded and those included in CMS reporting.


The authors reported: “From 2005 to 2011, 26% (408) of the 1,548 primary PCI cases were excluded from CMS reporting. This percentage increased over the study period from 13.9% in 2005 to 36.7% in the first three quarters of 2011 (p < 0.001).” The most common reason for exclusion was a diagnostic dilemma (e.g., a nondiagnostic initial electrocardiogram); these accounted for almost one-third of excluded patients. Another interesting finding was that 95% of CMS-included patients met DTB time goals in 2011, but this was true of only 61% of CMS-excluded patients in that year. Finally, the 1-year mortality for CMS-excluded patients was double that of CMS-included patients (13.5% vs. 6.6%).


The authors concluded that: “More than a quarter of patients who underwent primary PCI were excluded from hospital quality reports collected by CMS, and this percentage has grown substantially over time.” The implications of these findings according to the authors are important for understanding process improvement and reimbursement through P4P programs.


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.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Hospitals, Myocardial Infarction, Cardiology, Medicaid, Medicare, Reimbursement, Incentive, Angioplasty, Balloon, Coronary, Massachusetts, United States, Metric System, Physician Incentive Plans, Percutaneous Coronary Intervention

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