Month: September 2013

Door-To-Balloon Time, A Flawed Quality Metric

Some ideas simply sound good.  A cell starved of oxygen dies.  Acute coronary occlusions starve cells of oxygen.  Timely resolution of the occlusion restores oxygenated blood.  Time is myocardium.  Happy myocardium results in fewer deaths.

This is still true – but, not on the order of minutes.  This is a retrospective evaluation from the CathPCI registry, 1,400 hospitals in the U.S. that gather data for elective and emergency PCI.  They looked specifically at patients who received primary PCI at the presenting hospital for STEMI, with door-to-balloon times less than three hours.  Overall, between 2005 and 2009 – owing to door-to-balloon time as a quality measure – the median time decreased from 83 minutes to 67 minutes.

Unadjusted mortality?  4.8% at the beginning of the study period, 4.7% at the end.  They also did a risk-adjusted analysis – as there was some gradually decrease of healthy substrate over the study period.  This also showed no significant improvement in mortality.  Essentially, lots of graphs with door-to-balloon times decreasing, and mortality staying flat.

It is retrospective & observational, and there are always potential unmeasured confounders.  With 96,000 patients, however, chances are good they’re evenly distributed across groups.  Treatments have also changed over the last five years – although, one would expect those treatments would only contribute to improved mortality in the unadjusted analysis, if anything.

Just today, I was just listening to Stuart Swadron ranting away on Emergency Medical Abstracts about the endless process improvement meetings they have to shave fractions of time off door-to-balloon times for STEMI – he felt symptom-to-reperfusion was more important.  I’m sure he’s feeling in some way vindicated today.  Clearly on the micro-level, door-to-balloon probably doesn’t matter.  Use as a quality measure is probably overblown – particularly given the unanticipated consequences and resource utilization associated with these efforts.  More expenditure seems to have been less, again.

“Door-to-Balloon Time and Mortality among Patients Undergoing Primary PCI”
http://www.nejm.org/doi/full/10.1056/NEJMoa1208200

Colchicine for Pericarditis: Do It

Anti-inflammatory treatment is the mainstay of therapy for pericarditis.  Aspirin, NSAIDs, steroids – and now, colchicine.  Used to treat inflammation related to gouty attacks, useful in other types of serositis, colchicine has been suggested as having value in pericarditis, as well.

This is a seven-year double-blind, randomized controlled trial between colchicine and placebo, added to usual therapy – which, in this case, was usually aspirin.  Primary outcome was “incessant or recurrent pericarditis” – and, there’s no doubt in this trial the colchicine is successful and mostly harmless.  With standard anti-inflammatory treatment 37% of patients suffered incessant or recurrent pericarditis within the 18-month follow-up period, compared with 16.7% of patients receiving colchicine.  Colchicine had beneficial effect on symptom persistence at 72 hours – 40.0% vs. 19.2% – and was superior with remission at one week – 58.3% vs. 85.0%.

Adverse effects and drug discontinuation rates were essentially identical within the bounds of their relatively small sample size.  I don’t see any particular reason to exclude appropriate patients from colchicine for acute pericarditis.

“A Randomized Trial of Colchicine for Acute Pericarditis”
http://www.ncbi.nlm.nih.gov/pubmed/23992557

Still Looking For Positive EHR Effects

Our health system just underwent an upgrade from the 2009 version of an EHR to the 2012 version.  The color scheme is a little different.  The painfully cluttered workflow is not significantly changed.  I’m sure there are many Very Important Features – likely relating to burdensome documentation regulations – but, from a clinical standpoint, it still feels like we’re working with Windows 3.1.

But, we suffer this hacked together kludge because of the promise for tangible improvements in quality of care.  One area that has markedly changed with the advent of EHR is the ability to obtain significant medical histories on our patients – without the need to rely on the imperfect patient interview.  The hope of these authors was that, if they compared patients for whom they had complete records established in the EHR to patient who were EHR naive at their facility, they’d be able to demonstrate improvements in at leasts surrogate markers for patient-oriented outcomes.

Looking retrospectively at three EDs covering 13,227 patient visits, these authors found essentially statistical noise.  Comparing multiple outcomes including hospitalization, ED LOS, quantity lab orders, and hospital mortality, they found inconsistently distributed variation that is more likely attributed to unmeasured confounders than any element of the EHR itself.

Like most folks using EHRs, I suspect there are small, difficult-to-measure improvements in healthcare delivery.  Interoperability and centralized data sources would contribute vastly, I hope, to reduced testing and admission rates without adverse effects on outcomes.  However, we’re still waiting for proof.

“The impact of electronic health records on people with diabetes in three different emergency departments”
http://www.ncbi.nlm.nih.gov/pubmed/23842938