Registries as a Fundamental Tool to Improve Quality of Care

Randomized clinical trials (RCTs) are fundamental to demonstrate the efficacy of a particular intervention, but are subject to a design based on ideal conditions, with the resulting introduction of selection biases of patients in the participant centers, biases in the use of subgroup analyses that were not originally planned and publication bias. (1, 2) Therefore, once clinical trials have demonstrated the efficacy of a clinical intervention, the path is open for registries and observational studies to test the impact of such intervention in real practice. (3) Thus, registries are essential to verify if health care is delivered according to the recommendations of Clinical Practice Guidelines (CPG), completing the loop between clinical research (CR), guideline development and their implementation into clinical practice. In summary, RCTs demonstrate efficacy, while registries show effectiveness, efficiency and safety, and constitute a tool of inestimable value towards continuous quality improvement. This happens with the treatment of STEMI using primary percutaneous coronary intervention (PCI), which has proved to be the most effective reperfusion strategy when it is performed within a determined time interval. However, CPG cannot disregard the responsibility of professionals to make the appropriate decisions in the setting of any particular patient, shifting from the emphasis placed on diagnosis-based medicine to prognosis-based medicine due to the advances that will allow the individualization of what is now considered the standard. In the case of STEMI, the benefits of reperfusion strategies should be evaluated according to the time from the onset of symptoms, counterbalancing the benefits with the potential risks. In order for measurement of clinical variability to become more credible to professionals and stimulate them towards this goal, information systems should be more precise, incorporating more reliable estimations about the severity and complexity of cases than those currently available. The article by Charask et al. (4) published in this issue of the Argentine Journal of Cardiology (4) aims to analyze the rate of transfer of ST-segment elevation myocardial infarction (STEMI) patients to centers with PCI capabilities, the reperfusion strategies adopted and the time delays of the system, two key points for the therapeutic success and mortality reduction of STEMI patients. (5) The study is based on the National Survey of STsegment Elevation Myocardial Infarction (ARGEN-IAMST). (6) With the participation of 1,661 patients and 247 centers (60% with PCI capabilities) and despite the limitation of a low representation, the registry provides valuable information that was not available so far. The results show that patients treated in situ have a high reperfusion rate (86%), particularly with primary PCI (83%). On the contrary, patients transferred to centers with PCI capabilities were 35% less likely to receive any reperfusion treatment and 49% less likely to undergo primary PCI. In patients transferred who underwent primary PCI, time delays were higher than those recommended, particularly due to delays related to transportation (the door-to-balloon time was 85 minutes, but with a delay in transfer of approximately 2 hours), placing the primary PCI benefit in a marginal situation. Moreover, only 16% of the patients received thrombolytic therapy before being transferred, with a door-to-needle time of 48 minutes. These data would support the idea of adopting a plan to optimize reperfusion strategy in patients transferred, such as the implementation of pharmacoinvasive treatment. According to the 2012 CPG of the European Society of Cardiology (ESC), (7) delays to treatment are the most readily available, measurable index of quality of care in STEMI and should be recorded in every hospital providing care to STEACS patients. When targets are not met, interventions would be needed to improve performance. In our environment, the ARIAM (Analysis of the