Discussion
The development of regional and/or national programmes
to measure performance indicators systematically and to
provide feedback to individual participating centres has
been strongly recommended by the European Society of
Cardiology.2 In compliance with this recommendation, on
the background of previous short-term nationwide BLITZ
surveys,12,13,19 ANMCO has launched the scout project
BLITZ 4 qualità.
Our findings demonstrate that pharmacological indicators
scored close or superior to the target of compliance
with the relevant recommendations in ≥90% of suitable
patients whereas this was not the case for non-pharmacological
process-of-care indicators. In fact, pre-hospital
ECG recording, timely delivery of reperfusion by either
primary PCI or fibrinolysis, counselling for smoking cessation
on discharge, and referral to cardiac rehabilitation programmes
were all markedly below target. With regard to
antithrombotic therapies, an excessive dose was often
administered, especially with unfractioned heparin, and
among patients with renal insufficiency, but intracranial
and retroperitoneal bleeding were very rare as well the need
for transfusion.
Quantitative improvements were observed during phase
II for 10 of the 30 indicators analysed, and were most
marked for pharmacological indicators. Smoke cessation
counselling was the single indicator showing the most
favourable change in phase II, probably because this can be
rapidly achieved by cooperation of the medical and nursing
staff. Pre-hospital ECG recording, speeding up delivery of
reperfusion and institutional referral to cardiac rehabilitation
programmes require specific allocation of resources
and more complex and time-consuming adjustments in the
process of care outside cardiology units and may not be
rapidly achievable.
Despite a high-risk profile, the in-hospital outcomes of
our population with STEMI compare favourably with
recently reported registries data20 and may appear to challenge
the validity of our indicator scores. Specifically, the
delay to primary PCI has to be considered as underestimated,
because we measured the ECG to primary PCI
delay, expected to be shorter than door to balloon time.
The main reason for this discrepancy may be due to the fact
that mostly high-volume interventional centres were
selected for participation and the high rate of reperfusion
− especially with primary PCI − is likely to have had a
strong impact on the favourable outcomes. Comparison
with the most recent data (period 4) from Euro Heart Survey
ACS III20 lends support to this hypothesis, since a higher
use of reperfusion (91.9 vs. 81.3%) in eligible patients, particularly
with primary PCI (78.1 vs. 64%) − albeit with
longer delays [ECG−primary PCI time 92 min (IQR
65-151) vs. door−artery time 45 min (IQR 26−84)] − was
associated with a lower acute mortality in our population
(4.1 vs. 6.6%). Improvements in the door-to-balloon time
in itself were also shown to be poorly correlated with acute
outcomes in a report from the Get With The Guidelines programme.
21 This observation is consistent with the impressive
absolute 6.5 and 5.7% reduction in acute mortality
observed in the Wien and Bologna STEMI registries,22,23
respectively, after a 21 and 18% increase in the rate of reperfusion
had been achieved, mostly by primary PCI, much
larger than expected on the sole basis of superiority of primary
PCI over fibrinolysis, verified in meta-analysis of
randomized controlled trials that demonstrated only a 2%
absolute reduction in mortality.24 Simply striving to achieve
a higher use of reperfusion in population with STEMI may
impact total mortality more than other initiatives (e.g.
shortening treatment delays, or shifting from fibrinolysis to
primary PCI) and should therefore be given a stronger
priority.
Similarly, the in-hospital mortality in our population
with NSTEMI was favourable (2.1 vs. 2.9%) if compared
to the GRACE registry,25 as well as death + reinfarction
(2.9 vs. 5.7%), despite a similar or worse baseline risk profile,
such as troponin elevation in 100 vs. 42.1%, age 72
years (IQR 62-80) vs. 68 years (IQR 57−77), Killip class
III−IV in 7.5 vs. 5.2%, and ST-segment deviation in 48.3
vs. 31.8%, in BLITZ 4 and in GRACE respectively. The
possible reasons for this finding are not clear although,
once again, a larger use of coronary revascularization may
be among the reasons: 60.2 vs. 30.5% of patients received
PCI/CABG in BLITZ 4 vs. GRACE, respectively. Because
a systematic early invasive approach has not been shown to
impact on short-term outcomes in NSTEACS,26,27 myocardial
revascularization is not considered a quality indicator
in this setting. However, analyses of randomized controlled
trials are based on the intention to treat principle (with frequent
crossover to revascularization), whereas early revascularization,
when actually performed, has been shown to
be associated with better outcomes.28
The use of reperfusion in eligible STEMI patients was
increased in phase II in centres with interventional facilities,
but not in those devoid of such facilities. In the latter
setting, patients reaching the emergency department and
being directly transferred for reperfusion may have been
missed for screening and enrolment. Due to this possible
bias, the observed performance of those centres should be
evaluated with caution and future assessments should
include recruitment of patients directly in the emergency
room.
Study limitations
The limitations of our work must be acknowledged and
should be addressed in our upcoming initiatives, as follows.
(1) No ad-hoc validation was performed of consecutive
enrolment and this limitation should be overcome in the
future by check of administrative data based on hospital
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Olivari et al. 9
discharge records. (2) Patients were recruited during two
narrow time windows and a short feed-back time was
allowed for performance improvement. The BLITZ 4 qualità
was intended as a pilot project, to investigate the applicability
of both the instant survey/feedback method, and
the use of a set of performance indicators. Results from this
pilot project will help in tailoring and targeting future
nationwide initiatives with permanent data collection. (3)
High-volume centres with interventional facilities were
preferentially selected for participation in this survey.
Inclusion of a larger proportion of non-tertiary centres is
advisable in future projects.
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