The relationship between the emergent primary percutaneous coronary intervention quality measure and inpatient
Rahul K Khare1, D Mark Courtney, Raymond Kang
1Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. rkhare@northwestern.edu
Insights
Hospitals excelling in timely percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) also demonstrate lower overall acute myocardial infarction (AMI) mortality rates. This suggests the time-to-PCI metric may reflect broader quality of care.
Area of Science:
- Cardiology
- Health Services Research
- Quality Improvement
Background:
- Emergent primary percutaneous coronary intervention (PCI) significantly reduces mortality in ST-segment elevation myocardial infarction (STEMI).
- The association between hospital performance on the time-to-PCI quality metric and overall acute myocardial infarction (AMI) mortality remains unclear.
Purpose of the Study:
- To determine if hospitals with higher performance on the time-to-PCI quality measure achieve lower mortality rates for all AMI patients.
- To assess the time-to-PCI metric as a potential proxy for overall AMI quality of care.
Main Methods:
- Analysis of 69,101 AMI admissions from 2006 Nationwide Inpatient Sample (NIS), American Hospital Association (AHA) survey, and CMS Hospital Compare data.
- Hospitals categorized into quartiles based on the percentage of emergent primary PCI admissions meeting the timeliness threshold.
- Random effects logistic regression used to analyze the association between time-to-PCI performance and inpatient mortality, adjusted for patient and hospital characteristics.
Main Results:
- Hospitals in the top quartile for time-to-PCI had a 4.3% mortality rate, versus 5.1% in the bottom quartile.
- Risk-adjusted analysis showed a 17% lower odds of inpatient death (OR=0.83, 95% CI=0.72-0.95) for patients at top-quartile hospitals compared to bottom-quartile hospitals.
Conclusions:
- Hospitals with higher time-to-PCI performance exhibit significantly lower overall AMI mortality rates.
- Efficient performance of emergent primary PCI correlates with better outcomes for all AMI patients, indicating the time-to-PCI measure's potential as a proxy for overall AMI care quality.
Background:
In the setting of acute ST-segment elevation myocardial infarction (STEMI), reperfusion therapy with emergent primary percutaneous coronary intervention (PCI) significantly reduces mortality. It is unknown whether a hospital's performance on the Centers for Medicare & Medicaid Services (CMS) quality metric for time from patient arrival to angioplasty is associated with its overall hospital acute myocardial infarction (AMI) mortality rate.
Objectives:
The objective of this study was to evaluate if hospitals with higher performance on the time-to-PCI quality measure are more likely to achieve lower mortality for patients admitted for any type of AMI.
Methods:
Using merged 2006 data from the Nationwide Inpatient Sample (NIS), the American Hospital Association (AHA) annual survey, and CMS Hospital Compare quality indicator data, we examined 69,101 admissions with an International Classification of Diseases, Ninth Revision (ICD-9)-coded principal diagnosis of AMI in the 116 hospitals that reported more than 24 emergent primary PCI admissions in that year. Hospitals were categorized into quartiles according to percentage of admissions in 2006 that achieved the primary PCI timeliness threshold (time-to-PCI quality measure). Using a random effects logistic regression model of inpatient mortality, we examined the significance of the hospital time-to-PCI quality measure after adjustment for other hospital and individual patient sociodemographic and clinical characteristics.
Results:
The unadjusted inpatient AMI mortality rate at the 27 top quartile hospitals was 4.3%, compared to 5.1% at the 32 bottom quartile (worst performing) hospitals. The risk-adjusted odds ratio (OR) of inpatient death was 0.83 (95% confidence interval [CI] = 0.72 to 0.95), or 17% lower odds of inpatient death, among patients admitted to hospitals in the top quartile for the time-to-PCI quality measure compared to the case if the hospitals were in the bottom 25th percentile.
Conclusions:
Hospitals with the highest and second highest quartiles of time-to-PCI quality measure had a significantly lower overall AMI mortality rate than the lowest quartile hospitals. Despite the fact that a minority of all patients with AMI get an emergent primary PCI, hospitals that perform this more efficiently also had a significantly lower mortality rate for all their patients admitted with AMI. The time-to-PCI quality measure in 2006 was a potentially important proxy measure for overall AMI quality of care.
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