Download How to evaluate healthcare systems in primary angioplasty

European Heart Journal Supplements (2014) 16 (Supplement A), A45–A47
doi:10.1093/eurheartj/sut011
How to evaluate healthcare systems in primary
angioplasty
Francesco Fedele* and Massimo Mancone
Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, ‘Sapienza’ University
of Rome, Policlinico ‘Umberto I’, Viale del Policlinico 115, Italy
KEYWORDS
Primary PCI;
STEMI;
Quality evaluation;
Healthcare system
Primary percutaneous coronary intervention (P-PCI) is the gold-standard treatment for
ST-elevation myocardial infarction (STEMI). The main goals of a healthcare system in
the setting of STEMI are two: first of all to reduce the time delays between diagnosis
and P-PCI; secondly to increase the per cent of STEMI patients treated with P-PCI. The
aim of this article was to propose a quality evaluation of healthcare system, identifying
and defining measurable elements in the setting of P-PCI.
Primary percutaneous coronary intervention (P-PCI) represents the gold-standard treatment for patients presenting
with ST-elevation myocardial infarction (STEMI). Primary
percutaneous coronary intervention has become the
leading mode of reperfusion and the standard of treatment
in the majority of European countries, in the USA, and in
other ‘developed’ nations. Nevertheless, numerous differences exist in terms of time and rates of utilization of P-PCI,
among nations and also in singular country regions.1,2 In
Europe, beginning from 2003, a progressive raise of STEMI
patients reperfused with P-PCI was observed. In this
setting, the leading example is represented by Czech Republic, where the rate of P-PCI reperfused hospitalized
STEMI is more than 90%. These differences are mainly due
to: lack of interventional cardiologists and/or nurses and
other support staff; cultural problems (internists and noninvasive cardiologists prefer use thrombolysis); geographical differences (rural and urban areas); the presence of a
faulty network.2 The main goals of a healthcare system in
the setting of STEMI are two: first of all to reduce the
time delays between diagnosis and P-PCI; secondly to increase the per cent of STEMI patients treated with P-PCI.
An ‘operative’ Network organization, involving prehospitals services, community hospitals, and P-PCI
centres (‘24/7’), is crucial to ensure prompt, effective,
and accomplished myocardial reperfusion. Consequently,
* Corresponding author. Tel: +39 06 49979021; Fax: +39 06 49979060,
Email: [email protected]
a deepened quality evaluation of the healthcare system is
mandatory to point out ‘threatening crossroads’ and correctable defects.3,4 The aim of this article is to identify
and evaluate the chain rings that depict the ‘way’ of the
patient among diagnosis, P-PCI, hospital stay, discharge,
and follow-up. In literature, there are numerous papers
focalized to identify a correct methodology of quality assessment.3–5 The first step to analyze and evaluate a
healthcare system is to identify and to define measurable
elements. Measurable elements are normally derived
from guidelines. The majority of published papers on performance measures focalized their attention on the clinical
application of international guidelines.
Identifying performance measures
The first measure to perform in a country or a region is the
per cent of the hospitalized STEMI patients treated with
primary PCI: the target should be a rate .90%. According
to ESC guidelines, diagnosis, achieving a 12-leads electrocardiography, should be performed at the time of first
medical contact (FMC). The FMC is the moment when the
starter shoots the gun and starts to count the seconds.
For this reason, to understand the definition of FMC is
crucial; it refers to the initial patient assessment independently from who (physician or para-medic) and where
(pre-hospital setting or hospital setting) starts the
contact. Considering the FMC we could have different
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2013.
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A46
F. Fedele and M. Mancone
Figure 1 The complex healthcare systems in primary angioplasty setting.
times and consequently delays. The key delays are: (i) the
patient delay (time between symptoms onset and FMC); (ii)
delay between FMC and diagnosis (it should be ≤10 min);
(iii) delay between FMC and the wire positioning in culprit
vessel during P-PCI (it should be ≤90 and ≤60 min in the
high-risk patients with large anterior infarct or in the
early presenter within 2 h); (iv) door to balloon time
(it refers to P-PCI-capable hospital and it should be
≤60 min).4 In particular, the delay between FMC and
P-PCI is the strongest indicator of quality of healthcare
systems. In fact, involving pre-hospitals services, community hospitals, and P-PCI centres, it reflects the entire
organization and the functionality of the STEMI network
in a defined geographic area. Differently, from a patient
perspective, the most important time is total ischaemic
time (delay between symptom on set and reperfusion),
in other world ‘time is muscle’. In fact, in a recent published paper, using cardiac magnetic resonance, we
demonstrated that the total ischaemic time determines
the extent of reversible and irreversible myocardial
damage.6 Nevertheless, in a recent published paper on
the New England Journal of Medicine, the authors retrospectively analyzed a population of 96.738 STEMI patients
treated with P-PCI. They observed a significant reduction
in terms of door-to-balloon time between the period
2005–06 and the period 2008–09 (83 vs. 67 min; P ,
0.001); however, the significant reduction of doorto-balloon time was not associated with a reduction in
30-day mortality.7 This paper suggests that the ‘Time’ is
not all, and additional strategies are needed to reduce
in-hospital mortality.
Other performance measures that should be evaluated
to analyze a correct therapeutic ‘way’ in a healthcare
system in the setting of P-PCI patients could be reassumed
schematically analysing the four different steps:
catheterization-laboratory; coronary care-unit; discharge; follow-up.4,5
Catheterization laboratory:
(i) Per cent of patients treated with: aspirin, clopidogrel,
prasugrel, ticagrelor, bivaluridin, unfractionated
heparin;
(ii) Per cent of patients treated with: drug-eluting stent,
thrombectomy, radial approach;
(iii) number of P-PCI/year, number of P-PCI/year/
operator.
Coronary care-unit, discharge and follow-up:
(i) length of stay in the coronary care unit; hospital stay;
(ii) per cent of patients treated and discharged with:
b-blockers, statin, angiotensin-converting enzyme
Evaluation of healthcare systems in primary angioplasty
(iii)
(iv)
(v)
(vi)
inhibitors, angiotensin-receptor blockers, aldosterone antagonists, DAPT;
assessment of infarct size and left ventricular function: echocardiography and/or cardiac magnetic resonance per cent;
per cent of multivessel patients evaluated for residual
ischaemia and viability;
per cent of patients that start a rehabilitation programme;
per cent of patients followed-up: to optimize therapy,
to identify patients who will need ICD or CRT;
re-hospitalization rate; mortality rate.
A47
2.
3.
4.
In conclusion, the evaluation of a healthcare system in the
primary angioplasty setting is complex and includes different
actors and perspectives. It starts from the patient-centred
approach and arrive to an international perspective, going
through physicians, para-medical figures, network organization, technology, hospitals, region and nations
(Figure 1).
5.
Conflict of interest: none declared.
6.
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