The Devil Is in the Details

Abstract

Public reporting of processes of care and outcomes in common diseases has occurred for many decades.1 More recently, the National Quality Forum and various professional societies have developed, endorsed, and maintained performance measures in many of these common diseases. These performance measures have allowed comparison of processes of care and risk-adjusted outcomes among physicians, hospitals, and regions. As the performance of primary percutaneous coronary intervention (PCI) has become the dominant reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI) in the United States, performance measures around primary PCI have shaped how physicians measure their own performance, how patients are informed about quality of STEMI care in their regions, and how payers make decisions about reimbursement for care for STEMI.2,3 One of these metrics, the door-to-balloon (D2B) time, has emerged as the primary measure to judge quality and determine reimbursement in hospitals performing primary PCI for STEMI patients. This has occurred because of the healthcare system’s ability to measure this process and the association between improvements in D2B times and improvements in mortality (both in-hospital and long-term). This measure has been used with the understanding of the limitations of focusing solely on clinical outcomes.4–6 In this “pay for performance” era, most cardiologists would agree that D2B times and STEMI performance measures in general are important components of measuring quality of care; however, the report by McCabe et al7 in this issue of Circulation shows that “the devil is in the details.” Article see p 194 The authors should be congratulated on their effort to examine this topic, and we believe that this report highlights a number of important issues when considering performance measures in STEMI patients. A total of 1548 …