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Pharmacoinvasive and Primary Percutaneous Coronary Intervention Strategies in ST-Elevation Myocardial Infarction (from the Mayo Clinic STEMI Network). Am J Cardiol 2016; 117:1904-10. [PMID: 27131614 DOI: 10.1016/j.amjcard.2016.03.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/21/2016] [Accepted: 03/21/2016] [Indexed: 12/24/2022]
Abstract
The effectiveness of a pharmacoinvasive strategy consisting of fibrinolysis and transfer for percutaneous coronary intervention (PCI) compared to primary PCI (PPCI) in patients presenting to non-PCI-capable hospitals with ST-elevation myocardial infarction (STEMI) is not well defined. We analyzed data from the Mayo Clinic STEMI database of patients treated with a pharmacoinvasive strategy (favored in those presenting early after symptom onset) or PPCI in a regional STEMI network from 2004 to 2012. A total of 364 and 1,337 patients were included in the pharmacoinvasive and PPCI groups, respectively. Patients in the PPCI group were older and more frequently had cardiogenic shock at the time of presentation (12.1% vs 7.7%, p = 0.018). Death from any cause occurred in 58 (16%) and 314 (23%) patients in the pharmacoinvasive and PPCI groups, respectively (median follow-up 3.9 and 4.4 years, respectively). In multivariate analyses adjusting for age, gender, and other variables for which the 2 groups differed at baseline, there was no significant difference between the 2 strategies for 30-day (hazard ratio 0.66, 95% confidence interval 0.36 to 1.21) or overall mortality (hazard ratio 0.84, 95% confidence interval 0.63 to 1.12). Shorter door-to-balloon time was associated with increased effectiveness of PPCI (p for trend = 0.015), but there was no difference between the 2 strategies even when considering only the patients with door-to-balloon time in the lowest quartile. In conclusion, fibrinolysis followed by transfer for PCI represents a reasonable alternative when PPCI is not readily available especially in patients presenting early after symptom onset.
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Langabeer JR, Smith DT, Cardenas-Turanzas M, Leonard BL, Segrest W, Krell C, Owan T, Eisenhauer MD, Gerard D. Impact of a Rural Regional Myocardial Infarction System of Care in Wyoming. J Am Heart Assoc 2016; 5:JAHA.116.003392. [PMID: 27207968 PMCID: PMC4889203 DOI: 10.1161/jaha.116.003392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients presenting with ST‐segment elevation myocardial infarction; however, to be effective, PCI must be performed in a timely manner. Rural regions are at a severe disadvantage, given the relatively sparse number of PCI hospitals and long transport times. Methods and Results We developed a standardized treatment and transfer protocol for ST‐segment elevation myocardial infarction in the rural state of Wyoming. The study design compared the time‐to‐treatment outcomes during the pre‐ and postintervention periods. Details of the program, changes in reperfusion strategies over time, and outcome improvements in treatment times were reported. From January 1, 2013, to December 31, 2014, 889 patients were treated in 11 PCI‐capable hospitals (4 in Wyoming, 7 in adjoining states). Given the large geographic distance in the state (median of 47 miles between patient and PCI center), 52% of all patients were transfers, and 36% were administered fibrinolysis at the referral facility. Following the intervention, there was a significant shift toward greater use of primary PCI as the dominant reperfusion strategy (from 47% to 60%, P=0.002), and the median total ischemic time from symptom onset to arterial reperfusion was decreased by 92 minutes (P<0.001). There was a similar significant reduction in median time from receiving center door to balloon of 11 minutes less than the baseline time (P<0.01). Conclusions Rural systems of care for ST‐segment elevation myocardial infarction require increased levels of cooperation between emergency medical services agencies and hospitals. This study confirms that total ischemic times can be reduced through a coordinated rural statewide initiative.
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Brown JR, Rezaee ME, Nichols EL, Marshall EJ, Siew ED, Matheny ME. Incidence and In-Hospital Mortality of Acute Kidney Injury (AKI) and Dialysis-Requiring AKI (AKI-D) After Cardiac Catheterization in the National Inpatient Sample. J Am Heart Assoc 2016; 5:e002739. [PMID: 27068629 PMCID: PMC4943252 DOI: 10.1161/jaha.115.002739] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Acute kidney injury (AKI) and dialysis‐requiring AKI (AKI‐D) are common, serious complications of cardiac procedures. Methods and Results We evaluated 3 633 762 (17 765 214 weighted population) cardiac catheterization or percutaneous coronary intervention (PCI) hospital discharges from the nationally representative National Inpatient Sample to determine annual population incidence rates for AKI and AKI‐D in the United States from 2001 to 2011. Odds ratios for both conditions and associated in‐hospital mortality were calculated for each year in the study period using multiple logistic regression. The number of cardiac catheterization or PCI cases resulting in AKI rose almost 3‐fold from 2001 to 2011. The adjusted odds of AKI and AKI‐D per year among cardiac catheterization and PCI patients were 1.11 (95% CI: 1.10–1.12) and 1.01 (95% CI: 0.99–1.02), respectively. Most importantly, in‐hospital mortality significantly decreased from 2001 to 2011 for AKI (19.6–9.2%) and AKI‐D (28.3–19.9%), whereas odds of associated in‐hospital mortality were 0.50 (95% CI: 0.45–0.56) and 0.70 (95% CI: 0.55–0.93) in 2011 versus 2001, respectively. The population‐attributable risk of mortality for AKI and AKI‐D was 25.8% and 3.8% in 2001 and 41.1% and 6.5% in 2011, respectively. Males and females had similar patterns of AKI increase, although males outpaced females. Conclusions The Incidence of AKI among cardiac catheterization and PCI patients has increased sharply in the United States, and this should be addressed by implementing prevention strategies. However, mortality has significantly declined, suggesting that efforts to manage AKI and AKI‐D after cardiac catheterization and PCI have reduced mortality.
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Affiliation(s)
- Jeremiah R Brown
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Michael E Rezaee
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Elizabeth L Nichols
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Emily J Marshall
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Edward D Siew
- Geriatrics Research Education & Clinical Center (GRECC), Tennessee Valley Healthcare System (TVHS), Veteran's Health Administration, Murfreesboro, TN Division of Nephrology, Department of Medicine, Vanderbilt Center for Kidney Disease (VKCD), Vanderbilt University School of Medicine, Nashville, TN
| | - Michael E Matheny
- Geriatrics Research Education & Clinical Center (GRECC), Tennessee Valley Healthcare System (TVHS), Veteran's Health Administration, Murfreesboro, TN Division of General Internal Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
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Lu TH, Huang YT, Lee JC, Yang LT, Liang FW, Yin WH, Kawachi I. Characteristics of Early and Late Adopting Hospitals Providing Percutaneous Coronary Intervention in Taiwan. J Am Heart Assoc 2015; 4:JAHA.115.002840. [PMID: 26702079 PMCID: PMC4845258 DOI: 10.1161/jaha.115.002840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies in the United States suggested that the characteristics of hospitals providing percutaneous coronary intervention (PCI) differed from those not providing PCI. However, little is known on the differences between the characteristics of early-adopting hospitals and those of late-adopting hospitals, and on their potential impacts on PCI volume and access. METHODS AND RESULTS We used inpatient claims data from 1997 to 2012 from the Taiwan National Health Insurance program to identify the hospitals offering PCI. Geographic information systems (GIS) were used to determine the population access to PCI hospital. As of 2012, 88 hospitals were capable of providing PCI. On the basis of the year that the hospitals started providing PCI, 32 hospitals were designated as early adopters (before 1998), 23 as early majority (1998-2002), 24 as late majority (2003-2007), and 16 as laggards (2008-2012). Hospitals that adopted PCI later were smaller in size and closer to an existing PCI hospital and had lower PCI volumes performed and less bypass surgery support. The median PCI volumes in 2012 were n=706, 330, 138, and 81 in early adopters, early majority, late majority, and laggards, respectively. Despite the low volume of PCI performed in laggard hospitals, the percentage with ST-elevation myocardial infarction and acute myocardial infarction as principal discharge diagnosis was higher than their early-adopting hospital counterparts. The percentage of the Taiwanese population living within 40 km of PCI hospitals (appropriate access defined in this study) was 95.7% in 1997 and 98.0% in 2002, and this has remained unchanged since 2002. CONCLUSIONS The characteristics of early-adopting hospitals differed from those of late-adopting hospitals. Despite lower PCI volume performed in late-adopting hospitals, many of them are in remote areas and provide needed and timely services for patients with acute myocardial infarction.
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Affiliation(s)
- Tsung-Hsueh Lu
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan (T.H.L., J.C.L., F.W.L.)
| | - Yu-Tung Huang
- Program in Ageing and Long-term Care, Kaohsiuang Medical University, Kaohsiung, Taiwan (Y.T.H.)
| | - Jo-Chi Lee
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan (T.H.L., J.C.L., F.W.L.)
| | - Li-Tan Yang
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan (L.T.Y.)
| | - Fu-Wen Liang
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan (T.H.L., J.C.L., F.W.L.)
| | - Wei-Hsian Yin
- Division of Cardiology, Cheng Hsin General Hospital and Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan (W.H.Y.)
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Harvard University, Boston, MA (I.K.)
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Ward MJ, Baker O, Schuur JD. Association of Emergency Department Length of Stay and Crowding for Patients with ST-Elevation Myocardial Infarction. West J Emerg Med 2015; 16:1067-72. [PMID: 26759656 PMCID: PMC4703176 DOI: 10.5811/westjem.2015.8.27908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 08/14/2015] [Indexed: 11/23/2022] Open
Abstract
Introduction With the majority of U.S. hospitals not having primary percutaneous coronary intervention (pPCI) capabilities, the time spent at transferring emergency departments (EDs) is predictive of clinical outcomes for patients with ST-elevation myocardial infarction (STEMI). Compounding the challenges of delivering timely emergency care are the known delays caused by ED crowding. However, the association of ED crowding with timeliness for patients with STEMI is unknown. We sought to examine the relationship between ED crowding and time spent at transferring EDs for patients with STEMI. Methods We analyzed the Centers for Medicare and Medicaid Services (CMS) quality data. The outcome was time spent at a transferring ED (i.e., door-in-door-out [DIDO]), was CMS measure OP-3b for hospitals with ≥10 acute myocardial infarction (AMI) cases requiring transfer (i.e., STEMI) annually: Time to Transfer an AMI Patient for Acute Coronary Intervention. We used four CMS ED timeliness measures as surrogate measures of ED crowding: admitted length of stay (LOS), discharged LOS, boarding time, and waiting time. We analyzed bivariate associations between DIDO and ED timeliness measures. We used a linear multivariable regression to evaluate the contribution of hospital characteristics (academic, trauma, rural, ED volume) to DIDO. Results Data were available for 405 out of 4,129 hospitals for the CMS DIDO measure. These facilities were primarily non-academic (99.0%), non-trauma centers (65.4%), and in urban locations (68.5%). Median DIDO was 54.0 minutes (IQR 42.0,68.0). Increased DIDO time was associated with longer admitted LOS and boarding times. After adjusting for hospital characteristics, a one-minute increase in ED LOS at transferring facilities was associated with DIDO (coefficient, 0.084 [95% CI [0.049,0.119]]; p<0.001). This translates into a five-minute increase in DIDO for every one-hour increase in ED LOS for admitted patients. Conclusion Among patients with STEMI presenting to U.S. EDs, we found that ED crowding has a small but operationally insignificant effect on time spent at the transferring ED.
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Affiliation(s)
- Michael J Ward
- Vanderbilt University, Department of Emergency Medicine, Nashville, Tennessee
| | - Olesya Baker
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Jeremiah D Schuur
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Green JL, Nallamothu BK. Direct emergency medical services transport in STEMI: breaking the bank for non-PCI capable hospitals? Open Heart 2015; 2:e000139. [PMID: 26167289 PMCID: PMC4493164 DOI: 10.1136/openhrt-2014-000139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jacqueline L Green
- Division of Cardiovascular Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine , University of Michigan , Ann Arbor, Michigan , USA
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Hsia RY, Shen YC. Percutaneous Coronary Intervention in the United States: Risk Factors for Untimely Access. Health Serv Res 2015; 51:592-609. [PMID: 26174998 DOI: 10.1111/1475-6773.12335] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine how access to percutaneous coronary intervention (PCI) is distributed across demographics. DATA SOURCES Secondary data from the 2011 American Hospital Association (AHA) survey data combined with 2010 Census. STUDY DESIGN We calculated prehospital times from 32,370 ZIP codes to the nearest PCI center. We used a multivariate logit model to determine the odds of untimely access by the ZIP code's concentration of vulnerable populations. DATA COLLECTION We used ZIP code-level data on community characteristics from the 2010 Census and supplemented it with 2011 AHA survey data on service-line availability of PCI for responding hospitals. PRINCIPAL FINDINGS For approximately 306 million Americans, the median prehospital time to the nearest PCI center is 33 minutes. While 84 percent of Americans live within one hour of a PCI center, the odds of untimely access are higher in low-income (OR: 3.00; 95 percent CI: 2.39, 3.77), rural (8.10; 95 percent CI: 6.84, 9.59), and highly Hispanic communities (2.55; 95 percent CI: 1.86, 3.49). CONCLUSIONS While the majority of Americans live within 60 minutes of a PCI center, rural, low-income, and highly Hispanic communities have worse PCI access. This may translate into worse outcomes for patients with acute myocardial infarction.
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Affiliation(s)
- Renee Y Hsia
- Department of Emergency Medicine and Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
| | - Yu-Chu Shen
- Naval Postgraduate School, Monterey, CA.,National Bureau of Economic Research, Cambridge, MA
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Tisminetzky M, McManus DD, Erskine N, Saczynski JS, Yarzebski J, Granillo E, Gore J, Goldberg RJ. Thirty-day Hospital Readmissions in Patients with Non-ST-segment Elevation Acute Myocardial Infarction. Am J Med 2015; 128:760-5. [PMID: 25660250 PMCID: PMC4475427 DOI: 10.1016/j.amjmed.2015.01.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 01/08/2015] [Accepted: 01/09/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Limited data exist about relatively recent trends in the magnitude and characteristics of patients who are rehospitalized shortly after admission for a non-ST-segment elevation acute myocardial infarction (NSTEMI). This observational study describes decade-long trends (1999-2009) in the magnitude and characteristics of patients readmitted to the hospital within 30 days of hospitalization for an incident (initial) episode of NSTEMI. METHODS We reviewed the medical records of 2249 residents of the Worcester (Mass) metropolitan area who were hospitalized for an initial NSTEMI in 6 biennial periods between 1999 and 2009 at 3 central Massachusetts medical centers. RESULTS The average age of our study population was 72 years, 90% were white, and 46% were women. The proportion of patients who were readmitted to the hospital for any cause within 30 days after discharge for an NSTEMI remained unchanged between 1999 and 2009 (approximately 15%) in both crude and multivariable adjusted analyses. Slight declines were observed for cardiovascular disease-related 30-day readmissions over the 10-year study period. Women, elderly patients, those with multiple chronic comorbidities or a prolonged index hospitalization, and patients who developed heart failure during their index hospitalization were at higher risk for being readmitted within 30 days than respective comparison groups. CONCLUSION Thirty-day hospital readmission rates after hospital discharge for a first NSTEMI remained stable between 1999 and 2009. We identified several groups at higher risk for hospital readmission; further surveillance efforts and/or tailored educational and treatment approaches remain needed for these groups.
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Affiliation(s)
- Mayra Tisminetzky
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - David D McManus
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Nathaniel Erskine
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Jane S Saczynski
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester; Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Jorge Yarzebski
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Edgard Granillo
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Joel Gore
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester.
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Langabeer JR, Prasad S, Seo M, Smith DT, Segrest W, Owan T, Gerard D, Eisenhauer MD. The effect of interhospital transfers, emergency medical services, and distance on ischemic time in a rural ST-elevation myocardial infarction system of care. Am J Emerg Med 2015; 33:913-6. [PMID: 25910668 DOI: 10.1016/j.ajem.2015.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 04/01/2015] [Accepted: 04/01/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Regional myocardial infarction systems of care have been shown to improve timely access to primary percutaneous coronary intervention (PCI). However, there is a relatively sparse research on rural "frontier" regions. Arrival mode, high rates of interhospital transfers, long transport times, low population density, and mostly volunteer emergency medical services (EMS) distinguish this region from metropolitan systems of care. We sought to assess the effect of interhospital transfers, distance, and arrival mode on total ischemic times for patients with ST-elevation myocardial infarctions undergoing primary PCI. METHODS We assessed patient data from our observational cohort of 395 patients with ST-elevation myocardial infarction with PCI as their primary treatment strategy. Data came from the 10 PCI hospitals participating in the Wyoming Mission: Lifeline program from January 2013 to September 2014. We performed both regression and tests of differences. RESULTS Median total ischemic time was nearly 2.7 times greater in transferred patients than those presenting directly (379 vs 140 minutes). Distance in miles traveled between patient's home and PCI facility was 2.5 times larger in transfer patients (51 vs 20 miles). Emergency medical services arrival was associated with 23% shorter total ischemic times than self-arrival. CONCLUSIONS Transfer patients from referral hospitals had significantly greater total ischemic time, and use of EMS was associated with significantly lower times. Transport distance was mixed in its effect. These findings suggest a continued focus on improving transitions between referral and receiving centers and enhancing coordination in rural systems of care to reduce the multiplier effect of transfers on total ischemic time.
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Affiliation(s)
| | - Sapna Prasad
- University of Texas Health Science Center, Houston, TX
| | - Munseok Seo
- University of Texas Health Science Center, Houston, TX
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Bangalore S, Gupta N, Généreux P, Guo Y, Pancholy S, Feit F. Trend in percutaneous coronary intervention volume following the COURAGE and BARI-2D trials. Int J Cardiol 2015; 183:6-10. [DOI: 10.1016/j.ijcard.2015.01.053] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 09/18/2014] [Accepted: 01/25/2015] [Indexed: 10/24/2022]
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Ward MJ, Kripalani S, Storrow AB, Liu D, Speroff T, Matheny M, Thomassee EJ, Vogus TJ, Munoz D, Scott C, Fredi JL, Dittus RS. Timeliness of interfacility transfer for ED patients with ST-elevation myocardial infarction. Am J Emerg Med 2015; 33:423-9. [PMID: 25618768 PMCID: PMC4385487 DOI: 10.1016/j.ajem.2014.12.067] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 12/29/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES Most US hospitals lack primary percutaneous coronary intervention (PCI) capabilities to treat patients with ST-elevation myocardial infarction (STEMI) necessitating transfer to PCI-capable centers. Transferred patients rarely meet the 120-minute benchmark for timely reperfusion, and referring emergency departments (EDs) are a major source of preventable delays. We sought to use more granular data at transferring EDs to describe the variability in length of stay at referring EDs. METHODS We retrospectively analyzed a secondary data set used for quality improvement for patients with STEMI transferred to a single PCI center between 2008 and 2012. We conducted a descriptive analysis of the total time spent at each referring ED (door-in-door-out [DIDO] interval), periods that comprised DIDO (door to electrocardiogram [EKG], EKG-to-PCI activation, and PCI activation to exit), and the relationship of each period with overall time to reperfusion (medical contact-to-balloon [MCTB] interval). RESULTS We identified 41 EDs that transferred 620 patients between 2008 and 2012. Median MCTB was 135 minutes (interquartile range [IQR] 114,172). Median overall ED DIDO was 74 minutes (IQR 56,103) and was composed of door to EKG, 5 minutes (IQR 2,11); EKG-to-PCI activation, 18 minutes (IQR 7,37); and PCI activation to exit, 44 minutes (IQR 34,56). Door-in door-out accounted for the largest proportion (60%) of overall MCTB and had the largest variability (coefficient of variability, 1.37) of these intervals. CONCLUSIONS In this cohort of transferring EDs, we found high variability and substantial delays after EKG performance for patients with STEMI. Factors influencing ED decision making and transportation coordination after PCI activation are a potential target for intervention to improve the timeliness of reperfusion in patients with STEMI.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232.
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, 1313 21st Ave, Nashville, TN 37232
| | - Theodore Speroff
- Departments of Medicine and Biostatistics, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Michael Matheny
- Departments of Biomedical Informatics and Medicine, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
| | - Eric J Thomassee
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN
| | - Daniel Munoz
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Carol Scott
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Joseph L Fredi
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN
| | - Robert S Dittus
- Department of Medicine, Institute for Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN; Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN
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Shah RU, Henry TD, Rutten-Ramos S, Garberich RF, Tighiouart M, Bairey Merz CN. Increasing Percutaneous Coronary Interventions for ST-Segment Elevation Myocardial Infarction in the United States. JACC Cardiovasc Interv 2015; 8:139-146. [DOI: 10.1016/j.jcin.2014.07.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 07/02/2014] [Indexed: 01/18/2023]
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Baron SJ, Yeh RW, Cohen DJ. The challenges of success: maintaining access to high-quality percutaneous coronary intervention in the face of declining procedural volumes. Circulation 2014; 130:1343-5. [PMID: 25189216 DOI: 10.1161/circulationaha.114.012640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Suzanne J Baron
- From the Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO (S.J.B., D.J.C.); and Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.Y.)
| | - Robert W Yeh
- From the Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO (S.J.B., D.J.C.); and Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.Y.)
| | - David J Cohen
- From the Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO (S.J.B., D.J.C.); and Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.W.Y.).
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Jneid H. Interplay between time of presentation, timeliness of reperfusion, and outcome after ST-segment-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes 2014; 7:637-9. [PMID: 25074373 DOI: 10.1161/circoutcomes.114.001151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hani Jneid
- From the Division of Cardiology, the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX.
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