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Door-to-balloon time and the determining factors in a tertiary cardiac center in Nepal.

ABSTRACT: BACKGROUND:Door-to-balloon (DTB) time of 90 min during primary angioplasty is considered as the benchmark duration. Shorter DTB time is preferable, and longer duration can have poor clinical outcomes. METHODS:A cross-sectional observational study of three months in Shahid Gangalal National Heart Center was conducted in which all patients undergoing primary angioplasty were included. The DTB time was calculated, and the different determining factors were studied. RESULTS:Seventy-nine patients undergoing primary percutaneous intervention were studied. The median DTB time was 79 minutes (Interquartile range [IQR] 59-115 min). Forty-six (58.2%) patients had a DTB time of less than 90 min. DTB time varied significantly with direct visit vs transfer (p = 0.029) and office time visit (9 am-5 pm) vs off time (5 pm-9 am) (p = 0.012). DTB time did not differ between any infarct-related vessels (p = 0.471), number of vessels involved (p = 0.638), and the added procedures (defibrillation, thrombosuction, and temporary pacemaker insertion) (p = 0.682) during angioplasty. No significant differences were recorded according to age (p = 0.330), gender (p = 0.254), hypertension (p = 0.073), diabetes (p = 0.487), heart failure (p = 0.316), and baseline left ventricular ejection fraction (LVEF) (p = 0.819). CONCLUSION:The median DTB time in primary angioplasty was less than 90 minutes. The significant determining factors were timing of hospital visit (office vs off time) and type of visit (direct vs transfer). There can be improvement in factors determining DTB time to lower it further.

SUBMITTER: Dhungel S

PROVIDER: S-EPMC6309874 | biostudies-literature | 2018 Dec

REPOSITORIES: biostudies-literature

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Door-to-balloon time and the determining factors in a tertiary cardiac center in Nepal.

Dhungel Sachin S Malla Rabi R Adhikari Chandramani C Maskey Arun A Rajbhandari Rajib R Sharma Ranjit R Nepal Himanshu H Rauniyar Binaya B Yadav Dharmanath D Limbu Deepak D Gautam Milan M Adhikari Ajay A Dhungel Safal S Upadhyay Hari H

Indian heart journal 20180827

<h4>Background</h4>Door-to-balloon (DTB) time of 90 min during primary angioplasty is considered as the benchmark duration. Shorter DTB time is preferable, and longer duration can have poor clinical outcomes.<h4>Methods</h4>A cross-sectional observational study of three months in Shahid Gangalal National Heart Center was conducted in which all patients undergoing primary angioplasty were included. The DTB time was calculated, and the different determining factors were studied.<h4>Results</h4>Sev ...[more]

PMID: 30595281

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Project description:BackgroundThe impact of reducing door-to-balloon time on hospital revenues, costs, and net income is unknown.MethodsWe prospectively determined the impact on hospital finances of (1) emergency department physician activation of the catheterization lab and (2) immediate transfer of the patient to an immediately available catheterization lab by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected financial data for 52 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention from October 1, 2004-August 31, 2005 and compared this group to 80 consecutive ST-elevation myocardial infarction patients from September 1, 2005-June 26, 2006 after protocol implementation.ResultsPer hospital admission, insurance payments (hospital revenue) decreased ($35,043 +/- $36,670 vs. $25,329 +/- $16,185, P = 0.039) along with total hospital costs ($28,082 +/- $31,453 vs. $18,195 +/- $9,242, P = 0.009). Hospital net income per admission was unchanged ($6962 vs. $7134, P = 0.95) as the drop in hospital revenue equaled the drop in costs. For every $1000 reduction in total hospital costs, insurance payments (hospital revenue) dropped $1077 for private payers and $1199 for Medicare/Medicaid. A decrease in hospital charges ($70,430 +/- $74,033 vs. $53,514 +/- $23,378, P = 0.059), diagnosis related group relative weight (3.7479 +/- 2.6731 vs. 2.9729 +/- 0.8545, P = 0.017) and outlier payments with hospital revenue>$100,000 (7.7% vs. 0%, P = 0.022) all contributed to decreasing ST-elevation myocardial infarction hospitalization revenue. One-year post-discharge financial follow-up revealed similar results: Insurance payments: $49,959 +/- $53,741 vs. $35,937 +/- $23,125, P = 0.044; Total hospital costs: $39,974 +/- $37,434 vs. $26,778 +/- $15,561, P = 0.007; Net Income: $9984 vs. $9159, P = 0.855.ConclusionAll of the financial benefits of reducing door-to-balloon time in ST-elevation myocardial infarction go to payers both during initial hospitalization and after one-year follow-up.Trial registrationClinicalTrials.gov ID: NCT00800163.

Project description:Background and Objectives: Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer with a highly unfavorable prognosis. Aims: Retrospective statistical analysis of patients with HCC in the field of liver cirrhosis treated at our center from the perspective of demography, and the effects of key changes in diagnostic and therapeutic procedures in the last 10 years on overall survival (OS) and earlier diagnosis. Materials and Methods: This study included 170 cirrhotic patients with HCC (136 men, 80%). Demographic and etiological factors and OS were analyzed based on distribution into three groups according to the period and key changes in diagnostic and therapeutic approaches (BCLC classification staging; standardization of protocol for transarterial chemoembolization (TACE) and the introduction of direct-acting antivirals (DAA) for the treatment of chronic viral hepatitis C (HCV); expansion of systemic oncological therapy). Results: The mean age at the time of diagnosis was 69.3 years (SD = 8.1), and etiology was as follows: non-alcoholic steatohepatitis (NASH) 39%, alcoholic liver disease (ALD) 36%, HCV 18%, cryptogenic liver cirrhosis 3%, chronic hepatitis B infection (HBV) 2%, and other etiology 2%. Distribution of stages according to the BCLC: 0 + A 36%, B 31%, C 22%, and D 11%. However, the distribution in the first studied period was as follows: 0 + A 15%, B 34%, C 36%, and D 15%; and in the last period: 0 + A 45%, B 27%, C 17%, and D 11%, and difference was statistically significant (p < 0.05). The median OS for stages 0 + A, B, C, and D was 58, 19, 6, and 2 months, respectively. During the monitored period, there was a visible increase in the etiology of ALD from 30% to 47% and a decrease in HCV from 22% to 11%. In patients treated with TACE (stage B), the median OS grew from 10 to 24 months (p < 0.0001) between the marginal monitored periods. Conclusions: We described a decreasing number of patients with HCV-related HCC during follow-up possibly linked with the introduction of DAA. In our cohort, an improvement in early-stage diagnosis was found, which we mainly concluded as a result of proper ultrasound surveillance, the institution of a HCV treatment center, and increased experience of our sonographers with an examination of cirrhotic patients. Lastly, we described significantly improved overall survival in patients with intermediate HCC treated by TACE, due to the increased experience of interventional radiologists with the method at our facility and an earlier switch to systemic therapy in case of non-response to TACE.

Project description:BackgroundRecent reductions in average door-to-balloon (D2B) times have not been associated with decreases in mortality at the population level. We investigated this seemingly paradoxical finding by assessing components of this association at the individual and population levels simultaneously. We postulated that the changing population of patients undergoing primary percutaneous coronary intervention (pPCI) contributed to secular trends toward an increasing mortality risk, despite consistently decreased mortality in individual patients with shorter D2B times.MethodsThis was a retrospective study of ST-elevation myocardial infarction (STEMI) patients who underwent pPCI between Jan 1, 2005, and Dec 31, 2011, in the National Cardiovascular Data Registry (NCDR) CathPCI Registry. We looked for catheterisation laboratory visits associated with STEMI. We excluded patients not undergoing pPCI, transfer patients for pPCI, patients with D2B times less than 15 min or more than 3 h, and patients at hospitals that did not consistently report data across the study period. We assessed in-hospital mortality in the entire cohort and 6-month mortality in elderly patients aged 65 years or older matched to data from the Centers for Medicare and Medicaid Services. We built multilevel models to assess the relation between D2B time and in-hospital and 6-month mortality, including both individual and population-level components of this association after adjusting for patient and procedural factors.Findings423 hospitals reported data on 150,116 procedures with a 55% increase in the number of patients undergoing pPCI at these facilities over time, as well as many changes in patient and procedural factors. Annual D2B times decreased significantly from a median of 86 min (IQR 65-109) in 2005 to 63 min (IQR 47-80) in 2011 (p<0·0001) with a concurrent rise in risk-adjusted in-hospital mortality (from 4·7% to 5·3%; p=0·06) and risk-adjusted 6-month mortality (from 12·9% to 14·4%; p=0·001). In multilevel models, shorter patient-specific D2B times were consistently associated at the individual level with lower in-hospital mortality (adjusted OR for each 10 min decrease 0·92; 95% CI 0·91-0·93; p<0·0001) and 6-month mortality (adjusted OR for each 10 min decrease, 0·94; 95% CI 0·93-0·95; p<0·0001). By contrast, risk-adjusted in-hospital and 6-month mortality at the population level, independent of patient-specific D2B times, rose in the growing and changing population of patients undergoing pPCI during the study period.InterpretationShorter patient-specific D2B times were consistently associated with lower mortality over time, whereas secular trends suggest increased mortality risk in the growing and changing pPCI population. The absence of association of annual D2B time and changes in mortality at the population level should not be interpreted as an indication of its individual-level relation in patients with STEMI undergoing primary PCI.FundingNational Heart, Lung, and Blood Institute.

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Door-to-balloon time and the determining factors in a tertiary cardiac center in Nepal.

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Door-to-balloon time and the determining factors in a tertiary cardiac center in Nepal.

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