Statewide Program Helps Improve Quality of Care

Nov 17, 2007
Implementation of a program in North Carolina to increase
the rate of coronary reperfusion (restoring blood flow to
the heart muscle) for heart attack significantly improved
the quality of care these patients received, according to a
study in JAMA being released early online to coincide with
its release at the American Heart Association’s annual
meeting. The study will be published in the November 28
print issue of JAMA.

ST-segment elevation myocardial infarction (STEMI; a
certain pattern on an electrocardiogram during a heart
attack) is a potentially lethal condition for which
specific therapies, administered rapidly, can reduce the
risk of death and illness. Despite more than two decades
of clinical trial evidence demonstrating significant
benefits from prompt coronary reperfusion, registries
continue to show that most patients are still treated too
slowly for reperfusion to be of maximal benefit, and many
are not treated at all, according to background information
in the article. The reasons for this are largely related to
systematic barriers.

James G. Jollis, M.D., of Duke University, Durham, N.C.,
and colleagues conducted a study to determine if
establishment of a coordinated statewide system of
reperfusion therapy for STEMI (Reperfusion of Acute
Myocardial Infarction in North Carolina Emergency
Departments [RACE] study), as exists for trauma, would
overcome systematic barriers and both decrease delays in
administering reperfusion therapy and increase the
frequency with which reperfusion was provided to eligible

The researchers focused on the coordination of each aspect
of care from the initial emergency medical response to
reperfusion itself, whether is was fibrinolytic therapy
(medication for dissolving blood clots) or primary
percutaneous coronary intervention (PCI; procedures such as
balloon angioplasty or stent placement used to open blocked
coronary arteries), whichever was most appropriate for a
given setting.

The study included 65 hospitals and associated emergency
medical systems (10 PCI hospitals and 55 non-PCI hospitals)
in five regions in North Carolina, and 1,164 patients with
STEMI (579 pre-intervention, 585 post-intervention)
eligible for reperfusion who were treated at PCI hospitals;
and 925 patients with STEMI (518 pre-intervention, 407
post-intervention) who were treated at non-PCI hospitals.
The authors examined the reperfusion times and rates three
months before (July – September 2005) and three months
after (January – March 2007) a year-long implementation.

Among patients presenting to PCI hospitals who underwent
primary PCI, the proportion with first door-to-device times
less than 90 minutes increased from 57 percent to 72
percent with a decrease in median (midpoint) time from 85
to 74 minutes. For patients transferred from a non-PCI
hospital to another hospital for primary PCI, median time
from first door-to-device declined from 165 minutes to 128

For patients presenting to the 55 non-PCI hospitals, median
door-in to door-out times decreased from 120 minutes to 71
minutes. Reperfusion times also improved for door-to-needle
times in non-PCI hospitals (35 to 29 minutes). For patients
treated at or transferred to PCI hospitals, clinical
outcomes including death, cardiac arrest, and cardiogenic
shock did not significantly change following the
intervention, although the study was not designed to
directly assess these outcomes.

“We have demonstrated that a statewide program focused on
the development of regional systems for STEMI reperfusion
can significantly improve quality of care. Further
research is needed to ensure that this and other programs
that demonstrate improvement in application of reperfusion
therapies lead to reduced mortality and morbidity from
acute myocardial infarction,” the authors conclude.

JAMA. 2007; 298(20) :( doi:10.1001/jama.298.20.joc70124).