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Hospital Transfers for PCI Rarely Fast Enough Few heart attack patients get transferred from community

hospitals for primary percutaneous coronary intervention (PCI) within the recommended 30-minute window, according to a national study. And, sex differences prevail for women who have an average 8.9 minutes longer response time for treatment than among men Only 9.7% of ST-segment elevation myocardial infarction (STEMI) patients transferred for PCI got in and out of the initial hospital within 30 minutes, Harlan . Krumholz, MD, of Yale University, and colleagues reported in the Nov. 28 issue of the Archives of Internal Medicine. The door-in to door-out time was at least an hour for most patients and exceeded 90 minutes for 31% in the analysis of hospital performance monitoring data from the Centers for Medicare and Medicaid Services (CMS). Prior research has shown a 56% higher risk of dying in the hospital with a door-in to door-out time of over 30 minutes, Krumholz' group noted. But a decade of failure to reach the benchmark despite strenuous efforts to speed up transfers points to "immovable obstacles," Rita F. Redberg, MD, MSc, of the University of California San Francisco and editor of the journal, argued in an accompanying editorial. "It is time to reconsider transferring patients with STEMI for primary PCI," she concluded. "Timely reperfusion by thrombolytics, not late primary PCI via transfer, will save lives." The most lives would be saved by giving thrombolytic therapy in the ambulance when patients can't be taken straight to a primary PCI hospital. "Transfer should not be performed unless the patient is at high risk and there is reason to believe that with transfer the patient will receive primary PCI within 60 minutes," Redberg added. CMS started collecting patient-level data on door-in to door-out time for STEMI transfers for primary PCI in 2009 as part of its hospital performance monitoring. Krumholz and colleagues retrospectively analyzed the mandatory reporting data on 13,776 such patients -- not limited to Medicare beneficiaries -- seen in 2009 at 1,034 hospitals reporting on at least five patients each. They found a median door-in to door-out time of 68 minutes. Just 1.3% of the hospitals had a median time of 30 minutes or less. Door-in to door-out times were over 43 minutes for 75% of patients with no contraindication to thrombolytic therapy, while 25% of these patients spent more than 110 minutes at the transferring hospital. For these patients, outcomes would likely have been better if they had gotten fibrinolytic therapy and then PCI within three to 24 hours, based on American College of Cardiology/American Heart Association performance measures for STEMI, the researchers noted. They pointed to "tremendous variability" in average transfer times not only among hospitals but also across patient groups and geographic areas. After adjustment for other factors, aspects associated with delayed transfer for primary PCI were (all P<0.001): African American ancestry, with a mean time of 9.1 minutes longer than among white patients Younger age, with 18- to 35-year olds averaging 18.3 minutes longer to transfer compared with 46- to 55-year olds

Contraindication to fibrinolytic therapy, with an average of 6.9 minutes longer than without contraindications Evaluation at a rural hospital, which delayed transfer 15.3 minutes compared with being seen at an urban hospital initially Evaluation at a hospital in New England versus the East and West North Central regions

"Although these findings could result from differences in presentation or other clinical factors, we cannot exclude the possibility that quality of care varies by these patient characteristics," Krumholz' group noted in the paper. Their analysis couldn't determine overall door-to-balloon time, as it lacked data on transit time to the second hospital or on how rapidly patients were treated once they arrived along with no data on patient outcomes. But the median time to transfer of over one hour for most patients suggested a clear challenge in getting patients reperfused within the recommended 90 minutes, which appeared to be more of a systematic problem than one due to legitimate reasons for delays in certain individual patients, the group concluded. : 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

Herrin J, et al "National performance on door-in to door-out time among patients transferred for primary percutaneous coronary intervention" Arch Intern Med 2011; 171: 1879-1886. Redberg RF "Reconsidering transfer for percutaneous coronary intervention strategy: time is of the essence" Arch Intern Med 2011; http://archinte.ama-assn.org/cgi/content/extract/archinternmed.2011.566v2