title: Door-to-drug and door-to-balloon times: where can we improve? Time to reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI).
abstract: BACKGROUND
  To better understand hospital performance in door-to-drug and door-to-balloon times for patients with STEMI, we examined hospital-level variation in key subintervals of door-to-drug time (door-to-electrocardiogram [ECG] and ECG-to-drug) and of door-to-balloon time (door-to-ECG, ECG-to-lab, lab-to-balloon). We sought to identify achievable subinterval times based on the experience of top performing hospitals.
  
  
  METHODS
  We conducted a cross-sectional analysis, using data from the National Registry of Myocardial Infarction, of admissions between January 1, 2001, and December 31, 2002 (20435 patients receiving fibrinolytic therapy in 693 hospitals, and 13387 patients receiving percutaneous coronary intervention in 340 hospitals). Using hierarchical regression modeling, we estimated hospital-level geometric means of each subinterval, adjusted for patient clinical characteristics. We ranked hospitals based on the proportion of patients treated within 30 minutes for door-to-drug time and 90 minutes for door-to-balloon times and compared adjusted subinterval times across these groups.
  
  
  RESULTS
  The higher performing hospitals (top 20%) in door-to-drug time and door-to-balloon times had significantly shorter times in nearly all subintervals compared with other hospitals, adjusted for patient clinical characteristics. Adjusted mean subinterval times in higher performing hospitals in door-to-drug time were 6.8 minutes (SD = 1.7) for door-to-ECG and 18.7 minutes (SD = 3.5) for ECG-to-drug. Adjusted mean subinterval times in higher performing hospitals in door-to-balloon time were 7.9 minutes (SD = 1.7) for door-to-ECG, 47.8 minutes (SD = 7.1) for ECG-to-lab, and 29.0 minutes (5.4) for lab-to-balloon, adjusted for patient clinical characteristics.
  
  
  CONCLUSIONS
  Substantial national attention is being directed at improving time to treatment of patients with STEMI. These data suggest achievable subinterval times for hospitals seeking to improve performance in this important quality indicator.
authors.affiliation: Division of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8088, USA.
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
authors.forename: Jeph
authors.initials: J
authors.lastname: Herrin
authors.forename: Yongfei
authors.initials: Y
authors.lastname: Wang
authors.forename: Robert L
authors.initials: RL
authors.lastname: McNamara
authors.forename: Martha J
authors.initials: MJ
authors.lastname: Radford
authors.forename: David J
authors.initials: DJ
authors.lastname: Magid
authors.forename: John G
authors.initials: JG
authors.lastname: Canto
authors.forename: Martha
authors.initials: M
authors.lastname: Blaney
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D003430:Cross-Sectional Studies; D004562:Electrocardiography; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis / Q000188:drug therapy / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000592:standards*; D013997:Time Factors
chemical_list: D005343:Fibrinolytic Agents