Dr. Marco Tubaro,
Quality indicators are of pivotal importance in the assessment of the quality of care, at any level (international, national, regional and hospital). Dr. Sorensen from Denmark presented the various components of the delays that occur in the care of STEMI patients. The first is the patient delay (i.e. the decision time to seek help), which is the longest and the most difficult to reduce. The REACT trial yielded not very good results in decreasing patient delay, particularly in the long term and in general, patient delay is difficult to handle as a quality indicator. In the US, the Door-to-balloon (D2B) alliance suggested several key-measures to reduce the time from first medical contact to PCI and this PCI-related delay can be used as a more operational quality indicator. Prof. Schiele from France presented the history and the present situation of the quality indicators, whose application started in US in 1998 from the Joint Commission, followed in 2006 by the establishment of a first set of performance measures and then by a list of important papers on reperfusion, performance measures both for NSTEMI and STEMI, methodology of performance indicator definition and selection, and finally a position paper on composite indicators. There is a debate on the relative advantages and drawbacks of outcome measures vs. process of care measures. Mortality rates seem to be a poor quality indicator, while process measures and particularly composite indicators can show some advantage. There are several techniques to select composite indicators, from linear combinations to regression-based composite indicators.
Prof. Quinn from the UK presented the experience of the MINAP registry (that includes England and Wales), which yields a comprehensive coverage of the whole spectrum of ACS. MINAP is focussed more on the processes than on the outcomes and included an all-comers population of patients with ACS, treated in all the hospitals of the country. Some important quality indicators are the percentage of patients treated with primary PCI within 150 min from the decision to call for help (emergency number), the use of secondary prevention measures and mortality. Ambulance clinical quality indicators are also widely addressed and data are available for every single ambulance service, related to percentage of patients treated with thrombolysis within 30 min or by primary PCI within 150 min. A publication of the ‘quality account’ from the NHS is available. The British Cardiovascular Society endorses the ESC guidelines, but NICE produces national guidance for UK and recently the NICOR (national institute for cardiovascular outcome research) has been founded. Recent decisions from the government on a ‘transparency agenda’ will make MINAP data be publicly available to the population. Prof. Vrints from Belgium presented the point of view of the WG Acute Cardiac Care of the ESC. The WG ACC has the task of improving the quality of cardiovascular care not only in the ICCUs, but also in the pre-hospital setting, in the various hospital facilities and in the secondary prevention phase. Administrative data are poor tools and clinically meaningful data should be provided by scientific societies to the public and to decision makers. In comparison with the US, the EU and ESC are lagging behind in developing performance measures for the assessment of the quality of care and a collaborative effort should start, involving not only cardiologists, but also the allied health professions, national societies and their WGs and hospital managers as well. For patients, short and long term outcome and quality of care are very important and there is an underestimation and an under-reporting of the data relative to long term follow-up and outcomes. A more holistic view of the quality of cardiovascular care is needed, with the use of composite measures, the inclusion of preventive measures and the creation of measures of efficiency and appropriate use. New EURobservational programmes and new snapshot registries are needed in the field of acute cardiovascular care.
Quality indicators in the management of ST-elevation myocardial infarction
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