In the JournalsPerspective

Statewide STEMI destination policies confer faster treatment times

Jacqueline L. Green
Jacqueline L. Green

Patients with STEMI in states with laws allowing emergency medical services to bypass non-PCI-capable hospitals were treated faster than those in states without such laws, according to a report from the American Heart Association Mission: Lifeline Program.

Jacqueline L. Green, MD, MPH, cardiologist at Piedmont Heart Institute in Fayetteville, Georgia, and colleagues analyzed 19,827 patients hospitalized for STEMI in 2013 and 2014 and listed in the National Cardiovascular Data Registry and Acute Coronary Treatment and Intervention Outcomes Network Registry.

The researchers compared patients from six states with bypass policies — Delaware, Iowa, Maryland, Massachusetts, North Carolina and Pennsylvania — with patients from six states without bypass policies — Connecticut, Minnesota, New York, South Carolina, Texas and Virginia. The states were matched based on region, hospital density and percent state participation in the registry. The patients were matched based on age, sex and comorbidities.

Outcomes of interest were reperfusion and receipt of timely PCI.

After adjustments, 57.9% of patients from the states with bypass policies received primary PCI within their relevant guideline-recommended time from first medical contact (95% CI, 53.2-63.5) compared with 47.5% of patients from states without bypass policies (95% CI, 43.4-51.7), Green and colleagues reported.

The time advantage was significant at 90 minutes (OR = 1.59; 95% CI, 1.19-2.12) and 120 minutes (OR = 1.44; 95% CI, 1.06-1.95) from first medical contact, according to the researchers.

There was a trend toward patients from the states with bypass policies being more likely to receive any reperfusion therapy (OR = 1.77; 95% CI, 0.96-3.24), Green and colleagues wrote.

“Our findings provide a compelling case for state-level policies that allow emergency medical services to take patients directly to the PCI-capable centers,” Green said in a press release. “A policy that improves access to timely care for even an additional 10% of patients could have a significant impact on a population level.”

In a related editorial, Paul N. Fiorilli, MD, and Daniel M. Kolansky, MD, both from the division of cardiovascular medicine at the Hospital of the University of Pennsylvania, wrote: “The care and outcomes of STEMI patients can be improved without increasing the number of PCI-capable hospitals. The results indicate that simply living in a state which has a statewide pre-hospital plan for EMS transport is associated with improved treatment times for heart attack patients. This improvement is certainly statistically significant, although the absolute magnitude of the improvement in terms of actual minutes saved from [first medical contact] to reperfusion is modest.” – by Erik Swain

Disclosures: Green, Fiorilli and Kolansky report no relevant financial disclosures. One author reports he serves as medical director for Zoll Medical.

Jacqueline L. Green
Jacqueline L. Green

Patients with STEMI in states with laws allowing emergency medical services to bypass non-PCI-capable hospitals were treated faster than those in states without such laws, according to a report from the American Heart Association Mission: Lifeline Program.

Jacqueline L. Green, MD, MPH, cardiologist at Piedmont Heart Institute in Fayetteville, Georgia, and colleagues analyzed 19,827 patients hospitalized for STEMI in 2013 and 2014 and listed in the National Cardiovascular Data Registry and Acute Coronary Treatment and Intervention Outcomes Network Registry.

The researchers compared patients from six states with bypass policies — Delaware, Iowa, Maryland, Massachusetts, North Carolina and Pennsylvania — with patients from six states without bypass policies — Connecticut, Minnesota, New York, South Carolina, Texas and Virginia. The states were matched based on region, hospital density and percent state participation in the registry. The patients were matched based on age, sex and comorbidities.

Outcomes of interest were reperfusion and receipt of timely PCI.

After adjustments, 57.9% of patients from the states with bypass policies received primary PCI within their relevant guideline-recommended time from first medical contact (95% CI, 53.2-63.5) compared with 47.5% of patients from states without bypass policies (95% CI, 43.4-51.7), Green and colleagues reported.

The time advantage was significant at 90 minutes (OR = 1.59; 95% CI, 1.19-2.12) and 120 minutes (OR = 1.44; 95% CI, 1.06-1.95) from first medical contact, according to the researchers.

There was a trend toward patients from the states with bypass policies being more likely to receive any reperfusion therapy (OR = 1.77; 95% CI, 0.96-3.24), Green and colleagues wrote.

“Our findings provide a compelling case for state-level policies that allow emergency medical services to take patients directly to the PCI-capable centers,” Green said in a press release. “A policy that improves access to timely care for even an additional 10% of patients could have a significant impact on a population level.”

In a related editorial, Paul N. Fiorilli, MD, and Daniel M. Kolansky, MD, both from the division of cardiovascular medicine at the Hospital of the University of Pennsylvania, wrote: “The care and outcomes of STEMI patients can be improved without increasing the number of PCI-capable hospitals. The results indicate that simply living in a state which has a statewide pre-hospital plan for EMS transport is associated with improved treatment times for heart attack patients. This improvement is certainly statistically significant, although the absolute magnitude of the improvement in terms of actual minutes saved from [first medical contact] to reperfusion is modest.” – by Erik Swain

Disclosures: Green, Fiorilli and Kolansky report no relevant financial disclosures. One author reports he serves as medical director for Zoll Medical.

    Perspective

    B. Hadley Wilson

    This is an important study. The basic finding is that in states with a program for sending patients with acute MI and STEMI to the PCI-capable hospitals, there are earlier reperfusion times than in states without an organized statewide policy.

    We have known for a while that systems of care have improved artery-opening times in MI, but that was in regions, but to quantify that at a state level is powerful. Only nine states have legislation stating that patients with STEMI will be transported by EMS teams to the nearest PCI hospital as opposed to any hospital — assuming the patient is stable; in some situations, it is not safe to go a further distance to a PCI-capable hospital.

    This is the first large study to show that statewide systems of care are very effective at opening arteries sooner across the board. Both the old metric of door-to-balloon times and the new metric of first medical contact-to-treatment times were improved in the states with the authority to send patients to the nearest PCI-capable hospital over any hospital.

    These findings should encourage states without such laws to pass legislation to bring about statewide regulations that will have patients with STEMI go to the nearest PCI-capable hospital. There are 28 states with mandatory regulations to send patients with trauma to the nearest trauma center as opposed to the nearest hospital, but only nine with similar regulations for STEMI, six of which were in this study. If the number of states with STEMI regulations rose to the same level as those with trauma regulations, more patients would benefit.

    I would like to see these findings reproduced in other states, and also to see if these programs reduce mortality. That’s a lot more difficult to do, but we should continue to work on that. Other studies have found that improving reperfusion times reduces mortality, but it has not yet been shown on a statewide level.

    Also of note, more than one-quarter of patients in this study transported themselves to the hospital or arrived in a private vehicle. If we can develop community literacy to call 911 so at least 90% of patients call 911 for signs and symptoms of chest pain, we might see even further improvement in reperfusion times and in outcomes.

    • B. Hadley Wilson, MD, FACC
    • Interventional Cardiologist
      Sanger Heart & Vascular Institute
      Atrium Health
      Clinical Professor of Medicine
      UNC School of Medicine
      Chair, Membership Committee, American College of Cardiology

    Disclosures: Wilson reports he helped develop the statewide program for sending patients with STEMI to PCI-capable hospitals in North Carolina, but had no role in writing or passing the legislation.

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