Cost reductions associated with a quality improvement initiative for patients with ST-elevation myocardial infarction.

BACKGROUND: Efforts to reduce door-to-balloon (DTB) times for patients presenting with an ST-elevation myocardial infarction (STEMI) are widespread. Reductions in DTB times have been shown to reduce short-term mortality and decrease inpatient length of stay (LOS) in these high-risk patients. However, there is a limited literature examining the effect that these quality improvement (QI) initiatives have on patient care costs. METHODS: A STEMI QI program (Cardiac Alert Team [CAT]) initiative was instituted in July 2006 at a single tertiary care medical center located in central Massachusetts. Information was collected on cost data and selected clinical outcomes for consecutively admitted patients with a STEMI. Differences in adjusted hospital costs were compared in three cohorts of patients hospitalized with a STEMI: one before the CAT initiative began (January 2005-June 2006) and two after (October 1, 2007-September 30, 2009, and October 1, 2009-September 30, 2011). RESULTS: Before the CAT initiative, the average direct inpatient costs related to the care of these patients was $14,634, which decreased to $13,308 (-9.1%) and $13,567 (-7.3%) in the two sequential periods of the study after the CAT initiative was well established. Mean DTB times were 91 minutes before the CAT initiative and were reduced to 55 and 61 minutes in the follow-up periods (p < .001). There was a nonsignificant reduction in LOS from 4.4 days pre-CAT to 3.6 days in both of the post-CAT periods (p = .11). CONCLUSIONS: A QI program aimed at reducing DTB times for patients with a STEMI also led to a significant reduction in inpatient care costs. The greatest reduction in costs was related to cardiac catheterization, which was not expected and was likely a result of standardization of care and identification of practice inefficiencies.

Sustaining and spreading reduced door-to-balloon times for ST-segment elevation myocardial infarction patients.

BACKGROUND: Prompt primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity. In 2004 the American College of Cardiology (ACC) and American Heart Association (AHA) set a goal to reduce door-to-balloon (D2B) time to < 90 minutes in 75% of STEMI cases. IMPLEMENTING THE STEMI INITIATIVE: In 2004, the STEMI/D2B leadership team broke down D2B time into four segments: door to data, data to diagnosis, diagnosis to decision, and decision to device. Each segment was examined for inefficiencies, duplication, and nonstandardization. In 2005, after the internal D2B processes and results showed improvement, the STEMI/D2B leadership team extended the project to prehospital emergency medical services. In 2006, UMass Memorial began to roll out a regional system for STEMI care to the 12 community hospitals in its service area without on-site PCI capabilities. RESULTS: In 2007, the STEMI program's first full year, D2B times averaged < or = 90 minutes in 94% of the 87 STEMI cases; 62% had a D2B of < or = 60 minutes. In 2008, 96% of the D2B times averaged < or = 90 minutes. Mortality rates following PCI for STEMI were 62% and 57% less than predicted in 2006 and 2007, respectively. In 2008 the D2B time for direct-admit STEMI patients averaged < 50 minutes. From December 2007 through April 2009 UMass Memorial achieved the new ACC/AHA metric of prehospital EKG to balloon in < or = 90 minutes for 64 (90%) of the 71 patients for whom a prehospital electrocardiogram was obtained. DISCUSSION: The D2B time process is being applied to other clinical venues; a vascular surgery project is underway to reduce "door-to-incision time" for patients with ruptured abdominal aortic aneurysms.