title: Hospital improvement in time to reperfusion in patients with acute myocardial infarction, 1999 to 2002.
abstract: OBJECTIVE
  The purpose of this study was to analyze recent trends in door-to-reperfusion time and to identify hospital characteristics associated with improved performance.
  
  
  BACKGROUND
  Rapid reperfusion improves survival for patients with acute ST-segment elevation myocardial infarction (STEMI).
  
  
  METHODS
  In this retrospective observational study from the National Registry of Myocardial Infarction (NRMI)-3 and -4, between 1999 and 2002, we analyzed door-to-needle and door-to-balloon times in patients admitted with STEMI and receiving fibrinolytic therapy (n = 68,439 patients in 1,015 hospitals) or percutaneous coronary intervention (n = 33,647 patients in 421 hospitals) within 6 h of hospital arrival.
  
  
  RESULTS
  In 1999, only 46% of the patients in the fibrinolytic therapy cohort were treated within the recommended 30-min door-to-needle time; only 35% of the patients in the percutaneous coronary intervention cohort were treated within the recommended 90-min door-to-balloon time. Improvement in these times to reperfusion over the four-year study period was not statistically significant (door-to-needle: -0.01 min/year, 95% confidence interval [CI] -0.24 to +0.23, p > 0.9; door-to-balloon: -0.57 min/year, 95% CI -1.24 to +0.10, p = 0.09). Only 33% (337 of 1,015) of hospitals improved door-to-needle time by more than one min/year, and 26% (110 of 421) improved door-to-balloon time by more than three min/year. No hospital characteristic was significantly associated with improvement in door-to-needle time. Only high annual percutaneous coronary intervention volume and location in New England were significantly associated with greater improvement in door-to-balloon time.
  
  
  CONCLUSIONS
  Fewer than one-half of patients with STEMI receive reperfusion in the recommended door-to-needle or door-to-balloon time, and mean time to reperfusion has not decreased significantly in recent years. Relatively few hospitals have shown substantial improvement.
authors.affiliation: Department of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8088, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: McNamara
authors.forename: Jeph
authors.initials: J
authors.lastname: Herrin
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
authors.forename: Edward L
authors.initials: EL
authors.lastname: Portnay
authors.forename: Jeptha P
authors.initials: JP
authors.lastname: Curtis
authors.forename: Yongfei
authors.initials: Y
authors.lastname: Wang
authors.forename: David J
authors.initials: DJ
authors.lastname: Magid
authors.forename: Martha
authors.initials: M
authors.lastname: Blaney
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: D015906:Angioplasty, Balloon, Coronary; D004562:Electrocardiography; D005260:Female; D019983:Guideline Adherence; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000503:physiopathology / Q000628:therapy*; D017410:Practice Guidelines as Topic; D015912:Thrombolytic Therapy; D013997:Time Factors; D014481:United States