Door-to-Balloon Time - Perfecting the Data

Nothing sells papers like bad news.

And no one wants to have bad news shared with the world, especially when you’re a hospital and especially when people can compare your hospital to other hospitals.

So yesterday, this article from the New York Times was brought to my attention. It is a “response” from hospitals found to have the “worst” heart attack care as measured by door-to-balloon times by the government’s "Hospital Compare" database. You see, the New York Times wanted to sell papers, so the New York Times reviewed the database and published the data in the papers, and lots of the “worst” hospitals were offered a chance to “respond” to the article and give their excuse why their data were less than perfect compared to other hospitals. Here's one such response:

John Easton, spokesman, University of Chicago Medical Center: "As an academic medical center on the South Side of Chicago serving a large indigent population, we faced several uncommon hurdles in minimizing the time it takes to assess patients in the emergency room, move them quickly to the catheterization laboratory and initiate definitive care. These include a disproportionate number of patients with co-morbid conditions — such as stroke, respiratory failure requiring intubation, or cardiac arrest requiring resuscitation — which require immediate treatment prior to transfer to the cath lab. We also see uncommonly frequent patient refusal to undergo angiography immediately. In recognition of the impact of such cases, Medicare recently developed systems that allow hospitals like ours to document and exclude these outlier cases. Despite these hurdles, our door-to balloon times have vastly improved in the last year thanks to an aggressive systems approach. Our average time for the last 10 cases in the database (up to December 2006) was 94.4 minutes. From July 1, 2006, until now, 80 percent of patients had a door-to-balloon time of less than 90 minutes, and 100 percent were treated within 120 minutes."

Now all cardiologists understand the importance of opening an artery in the throws of an acute heart attack. Time is muscle. There is no question that hospitals need to make it a priority to open arteries as quickly as possible. In fact, this was felt to be so important that the American College of Cardiology initiated their “Door-to-Balloon - D2B” as a measure to assure excellent care. And the department of Health and Human Services added the criteria of door-to-balloon time to their database to assure that hospitals are providing exceptional heart attack care and provide incentives to hospital in terms of higher Medicare reimbursements to reward “quality.” Fair enough.

But when hospitals get embarrassed publicly once the data are actually used, they are forced to improve their data. So the natural consequence of these disclosures is that hospitals must change something quickly to assure they aren't on the CMS's blacklist. So the question becomes, is patient care at these centers improving or are the data collection and reporting improving by becoming more selective?

Here’s how I see this. Data using all patients' door-to-balloon times were initially entered into the government’s database in a differential fashion between centers. Some centers entered all of their patients that presented with heart attacks, others use highly "selective" criteria about whom to include in the reporting. These data are then exposed to the world in the New York Times. Hospitals are embarrassed and devise ways to improve their data using “aggressive systems approaches” to look good. Data become meaningless. Hospitals (and states) can use meaningless data to promote how great they are. Medicare decides to pay these hospitals because they have corrected the way they collect the data to make the data look good.

Everyone wins.

Except the patient. You see to avoid embarrasment and to ensure reimbursement from Medicare, all data will eventually skew toward “perfection” in the interest of marketing and payment forces.

So, how could hospitals possibly do this? Well, you get better at collecting data. You see, your “aggressive systems approach” looks carefully at the ACC guidelines and notes there are these helpful “exclusions” so the data collection teams can “exclude” reporting on patients that did not receive an angioplasty in 120 minutes because:

• Traffic was bad and prevented the angioplasty team from getting to the hospital in time
• Patient initially refused the procedure
• Angioplasty held due to concerns about possible aortic dissection
• Patient wanted to wait for family or clergy to arrive.
Patient had to be defibrillated several times before transfer to the lab
• Patient arrived in full cardiac arrest

You employ people to make sure that they find as many exclusions as possible to assure the data look good. Oh, and if your EKG doesn’t show ST segment elevation, then you don’t have to include those either - like posterior infarctions that rarely demonstrate ST segment elevation. But hey, it’s all about the quality of the data, isn’t it?

-Wes