Long-term effects of a standardized feedback-driven quality improvement program for timely reperfusion therapy in regional STEMI care networks

Karl Heinrich Scholz; Björn Lengenfelder; Claudius Jacobshagen; Claus Fleischmann; Hiller Moehlis; Hans G Olbrich; Jens Jung; Lars S Maier; Sebastian Kg Maier; Kurt Bestehorn; Tim Friede; Thomas Meyer

doi:10.1177/2048872620907323

Long-term effects of a standardized feedback-driven quality improvement program for timely reperfusion therapy in regional STEMI care networks

Eur Heart J Acute Cardiovasc Care. 2021 May 25;10(4):397–405. doi: 10.1177/2048872620907323. Epub 2020 Jul 29.

Authors

Karl Heinrich Scholz¹, Björn Lengenfelder^{2

3}, Claudius Jacobshagen⁴, Claus Fleischmann⁵, Hiller Moehlis⁶, Hans G Olbrich⁷, Jens Jung⁸, Lars S Maier⁹, Sebastian Kg Maier^{3

10}, Kurt Bestehorn¹¹, Tim Friede^{12

13}, Thomas Meyer^{13

14}

Affiliations

¹ Department of Cardiology, St Bernward Hospital, Hildesheim, Germany.
² Department of Cardiology, University of Würzburg, Germany.
³ Comprehensive Heart Failure Center Würzburg, Würzburg, Germany.
⁴ Department of Cardiology, Heart Center, University of Göttingen, Göttingen, Germany.
⁵ Department of Cardiology, Klinikum Wolfsburg, Wolfsburg, Germany.
⁶ Department of Cardiology, Klinikum Darmstadt, Darmstadt, Germany.
⁷ Department of Cardiology, Asklepios Klinik Langen, Langen, Germany.
⁸ Department of Cardiology, Klinikum Worms, Worms, Germany.
⁹ Department of Cardiology, University Hospital Regensburg, Regensburg, Germany.
¹⁰ Department of Cardiology, Klinikum Straubing, Straubing, Germany.
¹¹ Institute for Clinical Pharmacology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
¹² Department of Medical Statistics, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany.
¹³ German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany.
¹⁴ Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany.

PMID: 32723177
DOI: 10.1177/2048872620907323

Abstract

Aims: Current European Society of Cardiology guidelines state that repetitive monitoring and feedback should be implemented for ST-elevation myocardial infarction (STEMI) treatment, but no evidence is available supporting this recommendation. We aimed to analyze the long-term effects of a formalized data assessment and systematic feedback on performance and mortality within the prospective, multicenter Feedback Intervention and Treatment Times in STEMI (FITT-STEMI) study.

Methods: Regular interactive feedback sessions with local STEMI management teams were performed at six participating German percutaneous coronary intervention (PCI) centers over a 10-year period starting from October 2007.

Results: From the first to the 10th year of study participation, all predefined key-quality indicators for performance measurement used for feedback improved significantly in all 4926 consecutive PCI-treated patients - namely, the percentages of patients with pre-hospital electrocardiogram (ECG) recordings (83.3% vs 97.1%, p < 0.0001) and ECG recordings within 10 minutes after first medical contact (41.7% vs 63.8%, p < 0.0001), pre-announcement by telephone (77.0% vs 85.4%, p = 0.0007), direct transfer to the catheterization laboratory bypassing the emergency department (29.4% vs 64.2%, p < 0.0001), and contact-to-balloon times of less than 90 minutes (37.2% vs 53.7%, p < 0.0001). Moreover, this feedback-related continuous improvement of key-quality indicators was linked to a significant reduction in in-hospital mortality from 10.8% to 6.8% (p = 0.0244). Logistic regression models confirmed an independent beneficial effect of duration of study participation on hospital mortality (odds ratio = 0.986, 95% confidence interval = 0.976-0.996, p = 0.0087). In contrast, data from a nationwide PCI registry showed a continuous increase in in-hospital mortality in all PCI-treated STEMI patients in Germany from 2008 to 2015 (n = 398,027; 6.7% to 9.2%, p < 0.0001).

Conclusions: Our results indicate that systematic data assessment and regular feedback is a feasible long-term strategy and may be linked to improved performance and a reduction in mortality in STEMI management.

Keywords: ST-segment elevation myocardial infarction (STEMI); feedback interventions; mortality; percutaneous coronary intervention (PCI); quality control measures; treatment times.