1. Comparing Hospital Performance in Door-to-Balloon Time Between the Hospital Quality Alliance and the National Cardiovascular Data Registry Brahmajee K. Nallamothu, MD, MPH, FACC, Yongfei Wang, MS, Elizabeth H. Bradley, PhD, Kalon K. L. Ho, MD, SM, FACC, Jeptha P. Curtis, MD, FACC, John S. Rumsfeld, MD, PhD, FACC, Frederick A. Masoudi, MD, MSPH, FACC, *Harlan M. Krumholz, MD, SM, FACC J Am Coll Cardiol 2007;50:1517-19

2. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:1517-19 DTB Time Comparison: Background Background: Data on hospital performance in door-to- balloon (DTB) times for patients with ST-segment elevation myocardial infarction (STEMI) are now collected and reported by numerous organizations. Objectives: Despite proliferation of these efforts to report DTB time, its consistency across data sources has not been examined. We therefore compared performance rankings for hospitals on DTB time using 2 prominent national data sources: 1) the Hospital Quality Alliance (HQA), a consortium of organizations including CMS and the Joint Commission; and 2) the National Cardiovascular Data Registry’s (NCDR) CathPCI Registry.

3. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:1517-19 DTB Time Comparison: Methods Data collected on DTB time from HQA and NCDR between January-December 2005 were used for this analysis. Data on DTB times at 241 “matched” hospitals in both data sets were compared. We ranked hospitals into quintiles of performance separately in HQA and NCDR data using 4 specifications of DTB time: 1) mean DTB time; 2) median DTB time; 3) % of patients with DTB times within 90 min; and 4) % of patients with DTB times within 120 min. We calculated weighted kappa coefficients for each comparison and also reported the proportion of hospitals that remained within similar quintiles between data sources.

4. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:1517-19 DTB Time Comparison: Results We found DTB times in 51.3 (22.9) patients per hospital in HQA and 57.9 (28.0) patients per hospital in NCDR, reflecting modest differences in patient selection criteria. However, there was similar comparability in the mean patient age (60.8 years vs. 60.6 years, respectively; p=0.31) and mean percentage of women (29.4% vs. 29.0%, respectively; p=0.62). Hospital median DTB times were longer in HQA compared with NCDR: 93.8 min vs. 87.7 min (p<0.001). The mean proportion of patients with DTB times within 90 min was 47.9% for HQA and 53.0% for NCDR.

5. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:1517-19 DTB Time Comparison: Results Agreement between hospital rankings based on DTB time in HQA and NCDR was only fair-to- moderate overall (kappas ranging from 0.32 to 0.56 depending on DTB specification). Agreement was worst for mean DTB time and greatest for the proportion of patients with DTB within 90 min. Even for the proportion of patients with DTB times within 90 min, only 47.7% of hospitals were in the same quintile for HQA and NCDR.

6. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:1517-19 DTB Time Comparison: Results

7. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:1517-19 DTB Time Comparison: Limitations Only 241 facilities and 2 data sources were examined; however, the 2 data sources represent influential programs. Unable to match patients directly across data sources which prevented us from identifying whether differences were secondary to cohort selection or abstraction techniques. Unable to judge which data source was more accurate: both have their strengths and weaknesses. Since 2005, measures in both have evolved to better reflect current approaches to assessing DTB time

8. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply. J Am Coll Cardiol 2007;50:1517-19 DTB Time Comparison: Conclusions We found only fair to moderate agreement between DTB times reported to HQA and NCDR by the same group of hospitals, leading to substantial differences in rankings of hospital performance between data sources. As measures evolve (e.g., DTB time has already undergone major modification since 2005), further work should assess strategies for improving harmonization across data sources in order to limit confusion and avoid potential undermining of national quality improvement efforts.