November 30th, 2011
Should FedEx Be in Charge of Primary PCI?
Federal Express built its business on being a leader in transportation and delivering on time. Perhaps the results of primary PCI in the U.S. would be better if FedEx ran the program.
In patients with acute MI who must be transferred to another hospital for primary PCI, experts agree that the door-in to door-out (so called, DIDO) time should not exceed 30 minutes. Two studies — one from the Get With the Guidelines ACTION Registry and the other from CMS data — show that only ≈10% of patients transferred for PCI in the U.S. are delivered on time (i.e., DIDO <30 minutes). Distressingly, DIDO was more than 90 minutes in about one third of patients and more than 110 minutes in 25%.
If primary PCI were a business (i.e., FedEx), the transfer unit of the company would be in bankruptcy proceedings.
Customers complain about packages that are delivered late, but little outrage is voiced over patients whose acute MI treatment is unnecessarily delayed, leading to a higher mortality. In fact, DIDO time has not changed much over the past 5 years, and the problem is not limited to rural hospitals. In another recent study from a hospital in a major metropolitan area, the median DIDO time was >130 minutes, even though four primary PCI-capable hospitals were located within 5 miles.
The message for hospitals that advocate transfer of primary PCI patients should be the same as it would be for FedEx: deliver the goods on time or get out of the business.
In an accompanying editorial, Rita Redberg notes that “modern thrombolytic strategies have substantially attenuated the mortality benefit of primary PCI over thrombolytic therapy such that differences are trivial except for the highest-risk subgroup.” For acute MI patients who present to a hospital without primary PCI capability, thrombolytic therapy should be administered, and transfer “should not be performed unless the patient is at high risk and there is reason to believe that with transfer the patient will receive primary PCI within 60 minutes.” Dr. Redberg also offers a short post on this topic here at CardioExchange.
If you were to present with an acute MI to a hospital without primary PCI capability, which would you choose: immediate thrombolytic therapy or transfer (without knowing what the DIDO time will be)?