on January 9, 2006
Published online before print January 9, 2006, doi: 10.1161/CIRCULATIONAHA.105.578195
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Submitted on July 22, 2005
From the Health Services Research and Development Center of Excellence (B.K.N.), Ann Arbor VA Medical Center, Ann Arbor, Mich; Department of Internal Medicine, Division of Cardiovascular Disease (B.K.N., E.R.B.), University of Michigan Medical School, Ann Arbor, Mich; Section of Health Policy and Administration, Department of Epidemiology and Public Health (E.H.B., H.M.K.), Yale University School of Medicine, New Haven, Conn; Section of Cardiovascular Medicine (Y.W., R.L.M., J.H., H.M.K.), and the Robert Wood Johnson Clinical Scholars Program (H.M.K.), Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn; Clinical Research Unit, Kaiser Permanente (D.J.M.), Denver, Colo; Department of Emergency Medicine (C.V.P.), Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pa; and Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Conn (H.M.K.). * To whom correspondence should be addressed. E-mail: harlan.krumholz{at}yale.edu.
Background--Hospitals with primary percutaneous coronary intervention (PPCI) capability may choose to predominately offer PPCI to their patients with ST-segment elevation myocardial infarction (STEMI), or they may selectively offer PPCI or fibrinolytic therapy based on patient and hospital-level factors. Whether a greater level of hospital specialization with PPCI is associated with better quality of care is unknown. Methods and Results--We analyzed data from the National Registry of Myocardial Infarction-4 to compare in-hospital mortality and times to treatment in STEMI across different levels of hospital specialization with PPCI. We divided 463 hospitals into quartiles of PPCI specialization based on the relative proportion of reperfusion-treated patients who underwent PPCI ( Conclusions--Greater specialization with PPCI is associated with lower in-hospital mortality and shorter door-to-balloon times in STEMI patients treated with PPCI.
Revised on November 10, 2005
Accepted on November 11, 2005
Relation Between Hospital Specialization With Primary Percutaneous Coronary Intervention and Clinical Outcomes in ST-Segment Elevation Myocardial Infarction. National Registry of Myocardial Infarction-4 Analysis
Brahmajee K. Nallamothu MD, MPH,
34.0%, >34.0 to 62.5%, >62.5 to 88.5%, >88.5%). Hierarchical multivariable regression assessed whether PPCI specialization was associated with better outcomes, after adjusting for patient and hospital characteristics, including PPCI volume. We found that greater PPCI specialization was associated with a lower relative risk of in-hospital mortality in patients treated with PPCI (adjusted relative risk comparing the highest and lowest quartiles, 0.64; P=0.006) but not in those treated with fibrinolytic therapy. Compared with patients at hospitals in the lowest quartile of PPCI specialization, adjusted door-to-balloon times in the highest quartile were significantly shorter (99.6 versus 118.3 minutes; P<0.001), and the likelihood of door-to-balloon times exceeding 90 minutes was significantly lower (relative risk, 0.78; P<0.001). Adjusting for PPCI specialization diminished the association between PPCI volume and clinical outcomes.
Key words: catheter ablation • myocardial infarction • angioplasty • reperfusion • fibrinolysis
This article has been cited by other articles:
 |
|
 |
|
  G. Guagliumi Emerging data and decision for optimizing STEMI management: the European perspective Eur. Heart J. Suppl., June 1, 2009; 11(suppl_C): C19 - C24. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. W. Armstrong, C. M. Westerhout, and R. C. Welsh Duration of Symptoms Is the Key Modulator of the Choice of Reperfusion for ST-Elevation Myocardial Infarction Circulation, March 10, 2009; 119(9): 1293 - 1303. [Full Text] [PDF]
|
|
|
|
 |
|
 A. Gruneir, K. L. Lapane, S. C. Miller, and V. Mor Does the Presence of a Dementia Special Care Unit Improve Nursing Home Quality? J Aging Health, October 1, 2008; 20(7): 837 - 854. [Abstract] [PDF]
|
|
|
|
 |
|
 J. E. Schneider, T. R. Miller, R. L. Ohsfeldt, M. A. Morrisey, B. A. Zelner, and Pengxiang Li The Economics of Specialty Hospitals Med Care Res Rev, October 1, 2008; 65(5): 531 - 553. [Abstract] [PDF]
|
|
|
|
|
|
C. E. Buller, Y. Fu, K. W. Mahaffey, T. G. Todaro, P. Adams, C. M. Westerhout, H. D. White, A. W.J. van 't Hof, F. J. Van de Werf, G. S. Wagner, et al. ST-Segment Recovery and Outcome After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction: Insights From the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) Trial Circulation, September 23, 2008; 118(13): 1335 - 1346. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. W. Stone Angioplasty Strategies in ST-Segment-Elevation Myocardial Infarction: Part I: Primary Percutaneous Coronary Intervention Circulation, July 29, 2008; 118(5): 538 - 551. [Full Text] [PDF]
|
|
|
|
|
|
G. W. Stone Angioplasty Strategies in ST-Segment-Elevation Myocardial Infarction: Part II: Intervention After Fibrinolytic Therapy, Integrated Treatment Recommendations, and Future Directions Circulation, July 29, 2008; 118(5): 552 - 566. [Full Text] [PDF]
|
|
|
|
|
|
E. R. Bates and B. K. Nallamothu Commentary: The Role of Percutaneous Coronary Intervention in ST-Segment-Elevation Myocardial Infarction Circulation, July 29, 2008; 118(5): 567 - 573. [Full Text] [PDF]
|
|
|
|
 |
|
 T. Rooney, E.D. Moloney, K. Bennett, D. O'Riordan, and B. Silke Impact of an acute medical admission unit on hospital mortality: a 5-year prospective study QJM, June 1, 2008; 101(6): 457 - 465. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 American College of Cardiology/American Heart Asso, Developed in Collaboration With the Canadian Cardi, Endorsed by the American Academy of Family Physici, 2007 Writing Group to Review New Evidence and Upda, E. M. Antman, M. Hand, P. W. Armstrong, E. R. Bates, L. A. Green, L. K. Halasyamani, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction J. Am. Coll. Cardiol., January 15, 2008; 51(2): 210 - 247. [Full Text] [PDF]
|
|
|
|
|
|
E. M. Antman, M. Hand, P. W. Armstrong, E. R. Bates, L. A. Green, L. K. Halasyamani, J. S. Hochman, H. M. Krumholz, G. A. Lamas, C. J. Mullany, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the Canadian Cardiovascular Society Endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee Circulation, January 15, 2008; 117(2): 296 - 329. [Full Text] [PDF]
|
|
|
|
 |
|
 B Nallamothu, K A A Fox, B M Kennelly, F Van de Werf, J M Gore, P G Steg, C B Granger, O H Dabbous, E Kline-Rogers, K A Eagle, et al. Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary intervention. The Global Registry of Acute Coronary Events Heart, December 1, 2007; 93(12): 1552 - 1555. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. E. Boden, K. Eagle, and C. B. Granger Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction: A Comprehensive Review of Contemporary Management Options J. Am. Coll. Cardiol., September 4, 2007; 50(10): 917 - 929. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. R. Dixon, C. L. Grines, and W. W. O'Neill The Year in Interventional Cardiology J. Am. Coll. Cardiol., July 17, 2007; 50(3): 270 - 285. [Full Text] [PDF]
|
|
|
|
 |
|
 E. C. Keeley and L. D. Hillis Primary PCI for Myocardial Infarction with ST-Segment Elevation N. Engl. J. Med., January 4, 2007; 356(1): 47 - 54. [Full Text] [PDF]
|
|
|
|
 |
|
 A. Schomig, G. Ndrepepa, and A. Kastrati Late myocardial salvage: time to recognize its reality in the reperfusion therapy of acute myocardial infarction Eur. Heart J., August 2, 2006; 27(16): 1900 - 1907. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
The American Heart Association's Acute Myocardial, A. K. Jacobs, E. M. Antman, G. Ellrodt, D. P. Faxon, T. Gregory, G. A. Mensah, P. Moyer, J. Ornato, E. D. Peterson, et al. Recommendation to Develop Strategies to Increase the Number of ST-Segment-Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary Intervention Circulation, May 2, 2006; 113(17): 2152 - 2163. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. D. Henry, J. M. Atkins, M. S. Cunningham, G. S. Francis, W. J. Groh, R. A. Hong, K. B. Kern, D. M. Larson, E. M. Ohman, J. P. Ornato, et al. ST-Segment Elevation Myocardial Infarction: Recommendations on Triage of Patients to Heart Attack Centers: Is it Time for a National Policy for the Treatment of ST-Segment Elevation Myocardial Infarction? J. Am. Coll. Cardiol., April 4, 2006; 47(7): 1339 - 1345. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Specialization in Primary PCI Yields Better Outcomes Journal Watch Cardiology, March 16, 2006; 2006(316): 2 - 2. [Full Text]
|
|