Heart Attack Treatment 2.0

Nearly 400,000 Americans are transported to hospitals annually after exhibiting symptoms of ST-segment elevation myocardial infarction (STEMI), a major cause of heart attack. However, in 2005, the American College of Cardiology (ACC) reported that in over 60 percent of cases, U.S. providers failed to successfully treat heart attacks within 90 minutes of patients’ arrival to hospitals. This threshold between patients’ arrival and successful primary percutaneous coronary intervention (PCI), better known as balloon angioplasty, is known as the “door-to-balloon” time. With many studies demonstrating a strong correlation between “door-to-balloon” (D2B) time and patient mortality, the ACC responded in 2006 by launching the D2B Alliance, a nationwide campaign seeking to achieve door-to-balloon times of less than 90 minutes in over 75 percent of American hospitals, and in the process, significantly decrease mortality rates in heart attack cases.

The most common type of primary PCI, known as balloon angioplasty. Image courtesy of the Cleveland Clinic.

With over 1000 member hospitals, the D2B Alliance was a national effort to bring together health care professionals to implement coronary angioplasty treatment in a timely manner. To each participating hospital, it disseminated information via information packets, implementation toolkits, and webinars on evidence-based strategies to improve treatment times. In addition, the D2B online community – a web-based network intended as a forum for sharing information among health care professionals – was launched in November 2006. This network was the subject of a recent study by researchers at the Yale School of Public Health, who sought to determine the relationship between a campaign-sponsored online Listserv, or electronic mailing list, and reduction of D2B times.

The results of the study, recently published in BMJ Quality and Safety, indicated that use of the D2B online community had a positive but negligible effect on reducing treatment times. Approximately half of the 731 hospitals that were studied used the D2B online community, but it was found that over 36% of messages between November 2006 and July 2007 were sent by just 11 “high-volume” users who comprised only 5% of the community.

However, even though the study found no significant statistical association between use of the D2B online community and improved PCI treatment times, Ingrid Nembhard, Assistant Pro¬fessor of Public Health and Management and lead author of the paper, cautioned against presuming that online communities have little value for users. Over 60 percent of participators rated the helpfulness of the online community’s helpfulness as 4 or 5 on a 5-point scale; hence, a majority of users saw benefit in online community participation. However, that benefit was not reflected in changed D2B times. “It may be that other factors such as ability to implement proposed solutions moderate the relationship, or that change in D2B time is too distal an outcome measure,” Nembhard noted. “More research is needed to understand the benefits that users gain from online communities and when they are most helpful.”

In essence, even though statistical analyses suggested that the use of D2B online community had limited impact on performance improvement, it is possible that many of its other benefits were unaccounted for by the study. Nembhard noted that the D2B online community may have been providing significant social support, but these effects might not have directly translated into performance improvement and reduced times. Therefore, even though the authors of the study concluded that the D2B online community did not directly improve the timeliness of primary PCI treatment across America, they maintained that other potential benefits not statistically quantified in their study should be considered. “Online communities in health care may be valuable simply because they provide an information-sharing infrastructure that hasn’t existed before,” explained Nembhard. “To be able to have a context in which you can share ideas, technology, and practices across the country is a potentially amazing tool for improv¬ing patient care.”