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Wadhera RK, Joynt Maddox KE, Yeh RW, Bhatt DL. Public Reporting of Percutaneous Coronary Intervention Outcomes: Moving Beyond the Status Quo. JAMA Cardiol 2019; 3:635-640. [PMID: 29800962 DOI: 10.1001/jamacardio.2018.0947] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance More than 20 years have passed since public reporting of percutaneous coronary intervention (PCI) outcomes first began in New York State, but reporting remains a polarizing issue. Observations Advocates of public reporting point to the strong incentive that public disclosure of outcomes data provides for institutions and clinicians to improve clinical care and to the importance of enabling patients to make informed choices about their care. Critics highlight the methodological challenges that impede fair and accurate assessments of care quality as well as reporting's unintended consequences. Public reporting of PCI outcomes has only been implemented in 5 states, but reporting efforts for multiple conditions and procedures are now proliferating nationally, propelled by the notion that transparency improves the quality of health care and fosters trust in health care institutions. Careful evaluation of the evidence to date for PCI in particular, however, suggests that enthusiasm for such efforts should be tempered. Conclusions and Relevance Public reporting has not achieved its primary objectives. Policy makers should consider variations of reporting that might strengthen care quality, empower patients, and mitigate undesirable repercussions.
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Affiliation(s)
- Rishi K Wadhera
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts.,Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical, Harvard Medical School, Boston, Massachusetts
| | - Karen E Joynt Maddox
- The Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
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2
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Abstract
Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality. Regional variations in reporting frameworks and survival mean the exact burden of OHCA to public health is unknown. Nevertheless, overall prognosis and neurological outcome are relatively poor following OHCA and have remained almost static for the past three decades. In this Series paper, we explore the aetiology of OHCA. Coronary artery disease remains the predominant cause, but there is a diverse range of other potential cardiac and non-cardiac causes to be aware of. Additionally, we describe how investigators and key stakeholders in resuscitation science have formulated specific Utstein data element domains in an attempt to standardise the definitions and outcomes reported in OHCA research so that management pathways can be improved. Finally, we identify the predictors of survival after OHCA and what primary and secondary prevention strategies can be instigated to mitigate the devastating sequelae of this growing public health issue.
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Affiliation(s)
- Aung Myat
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK; Division of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.
| | - Kyoung-Jun Song
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, South Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, South Korea
| | - Thomas Rea
- Division of General Internal Medicine, Harborview Medical Centre, University of Washington, Seattle, WA, USA
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3
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Hsia RY, Sabbagh S, Sarkar N, Sporer K, Rokos IC, Brown JF, Brindis RG, Guo J, Shen YC. Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction. West J Emerg Med 2017; 18:1010-1017. [PMID: 29085531 PMCID: PMC5654868 DOI: 10.5811/westjem.2017.8.34592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/12/2017] [Accepted: 08/08/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction California has led successful regionalized efforts for several time-critical medical conditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandated protocols exist to define regionalization of care. We aimed to study the trends in regionalization of care for STEMI patients in the state of California and to examine the differences in patient demographic, hospital, and county trends. Methods Using survey responses collected from all California emergency medical services (EMS) agencies, we developed four categories – no, partial, substantial, and complete regionalization – to capture prehospital and inter-hospital components of regionalization in each EMS agency’s jurisdiction between 2005–2014. We linked the survey responses to 2006 California non-public hospital discharge data to study the patient distribution at baseline. Results STEMI regionalization-of-care networks steadily developed across California. Only 14% of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population, but over half of these counties, representing 86% of California’s STEMI patient population, reached complete regionalization in 2014. We did not find any dramatic differences in underlying patient characteristics based on regionalization status; however, differences in hospital characteristics were relatively substantial. Conclusion Potential barriers to achieving regionalization included competition, hospital ownership, population density, and financial challenges. Minimal differences in patient characteristics can establish that patient differences unlikely played any role in influencing earlier or later regionalization and can provide a framework for future analyses evaluating the impact of regionalization on patient outcomes.
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Affiliation(s)
- Renee Y Hsia
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Sarah Sabbagh
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Nandita Sarkar
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Karl Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,Alameda County Emergency Medical Services Agency, Oakland, California
| | - Ivan C Rokos
- University of California, Los Angeles-Olive View Medical Center; Geffen School of Medicine, Los Angeles, California
| | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,San Francisco Emergency Medical Services Agency, San Francisco, California
| | - Ralph G Brindis
- University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies, San Francisco, California.,University of California, San Francisco, Department of Medicine, San Francisco, California
| | - Joanna Guo
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Yu-Chu Shen
- National Bureau of Economic Research, Cambridge, Massachusetts.,Naval Postgraduate School, Graduate School of Business and Public Policy, Monterey, California
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4
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Yin WH, Lu TH, Chen KC, Cheng CF, Lee JC, Liang FW, Huang YT, Yang LT. The temporal trends of incidence, treatment, and in-hospital mortality of acute myocardial infarction over 15years in a Taiwanese population. Int J Cardiol 2016; 209:103-13. [PMID: 26889592 DOI: 10.1016/j.ijcard.2016.02.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/08/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The study was conducted to examine the nationwide temporal trends of incidence, treatment, and short-term outcomes for acute myocardial infarction (AMI) over a 15-year period in Taiwan. METHODS We identified patients who were hospitalized for incident AMI between 1997 and 2011 from the inpatient medical claim dataset of the National Health Insurance Research Database. Age- and sex-adjusted incidence and in-hospital mortality rates were calculated for AMI, and separately for ST-segment elevation and non-ST-segment elevation myocardial infarction (STEMI and NSTEMI). RESULTS A total of 144,634 patients were identified. The incidence rates (per 100,000 population) of AMI increased from 30 in 1997 to 42 in 2011, which was mainly driven by the increase of NSTEMI. The in-hospital mortality rate after AMI decreased from 9.1% in 1997 to 6.5% in 2011, which was also driven by the case mortality rate for NSTEMI. Although the in-hospital mortality rates significantly decreased from 7.3% to 5.1% between 1997 and 2003 for STEMI, it did not change significantly from 2004 to 2011. Moreover, AMI patients undergoing revascularization treatment, particularly PCI, was the most important independent predictor for improved in-hospital survival. CONCLUSION The results of this study demonstrated a recent dramatic increase in the incidence rates and a decrease in short-term mortality in patients with NSTEMI; while the incidence and in-hospital morality of STEMI only modestly changed over time in Taiwan. Further quality improvement approaches for AMI prevention and treatment to favorably affect the incidence and outcomes from both major types of AMI are highly recommended.
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Affiliation(s)
- Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Tsung-Hsueh Lu
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Kuan-Chun Chen
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | | | - Jo-Chi Lee
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Fu-Wen Liang
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Tung Huang
- Program in Ageing and Long-term Care, Kaohsiuang Medical University, Kaohsiung, Taiwan
| | - Li-Tan Yang
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
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5
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Aggarwal B, Menon V. Recent advances in treatment of acute coronary syndromes. F1000PRIME REPORTS 2013; 5:56. [PMID: 24381731 PMCID: PMC3854689 DOI: 10.12703/p5-56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In this manuscript we highlight recent advances in the management of acute coronary syndromes. Efforts to minimize myocardial ischemia time through improved health care systems have resulted in significant success. In addition, new evidence in the areas of reperfusion therapy and pharmacological intervention has emerged. Percutaneous coronary intervention continues to evolve and new data concerning the superiority of the radial route, the use of improved stents and adjunctive therapy will be presented. We will highlight the changes that were made in international guidelines (from the American College of Cardiology/American Heart Association and the European Society of Cardiology) in the last 18 months in order to incorporate the latest evidence. Although significant advancements have been made in the management of acute coronary syndromes, the morbidity and mortality associated with this condition remains high, necessitating continued research in this field of cardiovascular medicine.
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Affiliation(s)
- Bhuvnesh Aggarwal
- Departments of Internal Medicine9500 Euclid Avenue, Cleveland, Ohio 44114USA
| | - Venu Menon
- Cardiovascular Medicine Cleveland Clinic9500 Euclid Avenue, Cleveland, Ohio 44114USA
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6
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Armstrong PW, Gershlick AH, Van de Werf F. Fibrinolysis or primary PCI in myocardial infarction. N Engl J Med 2013; 369:280; discussion page 281. [PMID: 23863056 DOI: 10.1056/nejmc1305999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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7
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Concannon TW, Nelson J, Kent DM, Griffith JL. Evidence of systematic duplication by new percutaneous coronary intervention programs. Circ Cardiovasc Qual Outcomes 2013; 6:400-8. [PMID: 23838110 DOI: 10.1161/circoutcomes.111.000019] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence suggests that recent and projected future investments in percutaneous coronary intervention (PCI) programs at US hospitals fail to increase access to timely reperfusion for patients with ST-segment elevation myocardial infarction. METHODS AND RESULTS We set out to estimate the annual number and costs of new PCI programs in US hospitals from 2004 to 2008 and identify the characteristics of hospitals, neighborhoods, and states where new PCI programs have been introduced. We estimated a discrete-time hazard model to measure the influence of these characteristics on the decision of a hospital to introduce a new PCI program. In 2008, 1739 US hospitals were capable of performing PCI, a relative increase of 16.5% (251 hospitals) over 2004. The percentage of the US population with projected access to timely PCI grew by 1.8%. New PCI programs were more likely to be introduced in areas that already had a PCI program with more competition for market share, near populations with higher rates of private insurance, in states that had weak or no regulation of new cardiac catheterization laboratories, and in wealthier and larger hospitals. CONCLUSIONS Our data show that new PCI programs were systematically duplicative of existing programs and did not help patients gain access to timely PCI. The total cost of recent US investments in new PCI programs is large and of questionable value for patients.
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9
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Solla DJF, de Mattos Paiva Filho I, Delisle JE, Braga AA, de Moura JB, de Moraes X, Filgueiras NM, Carvalho ME, Martins MS, Neto OM, Filho PR, de Souza Roriz P. Integrated Regional Networks for ST-Segment–Elevation Myocardial Infarction Care in Developing Countries. Circ Cardiovasc Qual Outcomes 2013; 6:9-17. [DOI: 10.1161/circoutcomes.112.967505] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Regionalized integrated networks for ST-segment–elevation myocardial infarction (STEMI) care have been proposed as a step forward in overcoming real-world obstacles, but data are lacking on its performance in developing countries. We describe an integrated regional STEMI network in Salvador, Bahia, Brazil.
Methods and Results—
The network was created in 2009. It was coordinated by the prehospital emergency medical service and encompassed the public emergency system (prehospital mobile units, community-based emergency units, general hospitals, and cardiology reference centers). The 12-lead ECGs are interpreted via telemedicine. This network operates as follows: The Telemedicine Center sends each ECG suggestive of STEMI to a Regional STEMI Alert Team, which, together with emergency medical services, offers support for thrombolysis or immediate transfer for primary percutaneous coronary intervention. In 14 months, there were 433 suspected victims, of which in 287 (76.5%) the STEMI could be confirmed (age, 62.1±12.5 years; 63.4% men). Most of them were self-transported. The median pain-to-admission time was 180 minutes (interquartile range, 90–473 minutes), and the median admission-to-ECG time was 159.5 minutes (interquartile range, 83.5–340 minutes). The median interval time between the ECG and the telemedicine report was 31 minutes (interquartile range, 21–44 minutes). For those who sought medical attention and had an ECG performed within 12 hours after symptoms onset (n=119), the reperfusion rate was 75.6% (34.4% by thrombolysis and 65.6% by primary percutaneous coronary intervention).
Conclusions—
Regional STEMI networks may be feasible in developing countries. Preliminary results showed this network to be effective, achieving primary reperfusion rtes comparable with those reported internationally despite the obstacles faced.
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Affiliation(s)
- Davi Jorge Fontoura Solla
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Ivan de Mattos Paiva Filho
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Jacques Edouard Delisle
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Alecianne Azevedo Braga
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - João Batista de Moura
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Xavier de Moraes
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Nivaldo Menezes Filgueiras
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Marcela Embiruçu Carvalho
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Mariana Steque Martins
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Orlando Manganotti Neto
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Paulo Roberto Filho
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
| | - Pollianna de Souza Roriz
- From the Federal University of Bahia (D.J.F.S.) and Service d’Aide Médicale Urgente (D.J.F.S., I.d.M.P.F., A.A.B., N.M.F., M.E.C., M.S.M., O.M.N., P.R.F., P.d.S.R.), Salvador, Bahia, Brazil; Telemedicina da Bahia, Salvador, Bahia, Brazil (J.E.D.); and Agamenon Magalhães Hospital, Recife, Pernambuco, Brazil (J.B.d.M.X.d.M.)
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Clark CL, Berman AD, McHugh A, Roe EJ, Boura J, Swor RA. Hospital process intervals, not EMS time intervals, are the most important predictors of rapid reperfusion in EMS Patients with ST-segment elevation myocardial infarction. PREHOSP EMERG CARE 2011; 16:115-20. [PMID: 21999766 DOI: 10.3109/10903127.2011.615012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the relationship of emergency medical services (EMS) intervals and internal hospital intervals to the rapid reperfusion of patients with ST-segment elevation myocardial infarction (STEMI). METHODS We performed a secondary analysis of a prospectively collected database of STEMI patients transported to a large academic community hospital between January 1, 2004, and December 31, 2009. EMS and hospital data intervals included EMS scene time, transport time, hospital arrival to myocardial infarction (MI) team activation (D2Page), page to catheterization laboratory arrival (P2Lab), and catheterization laboratory arrival to reperfusion (L2B). We used two outcomes: EMS scene arrival to reperfusion (S2B) ≤90 minutes and hospital arrival to reperfusion (D2B) ≤90 minutes. Means and proportions are reported. Pearson chi-square and multivariate regression were used for analysis. RESULTS During the study period, we included 313 EMS-transported STEMI patients with 298 (95.2%) MI team activations. Of these STEMI patients, 295 (94.2%) were taken to the cardiac catheterization laboratory and 244 (78.0%) underwent percutaneous coronary intervention (PCI). For the patients who underwent PCI, 127 (52.5%) had prehospital EMS activation, 202 (82.8%) had D2B ≤90 minutes, and 72 (39%) had S2B ≤90 minutes. In a multivariate analysis, hospital processes EMS activation (OR 7.1, 95% CI 2.7, 18.4], Page to Lab [6.7, 95% CI 2.3, 19.2] and Lab arrival to Reperfusion [18.5, 95% CI 6.1, 55.6]) were the most important predictors of Scene to Balloon ≤ 90 minutes. EMS scene and transport intervals also had a modest association with rapid reperfusion (OR 0.85, 95% CI 0.78, 0.93 and OR 0.89, 95% CI 0.83, 0.95, respectively). In a secondary analysis, Hospital processes (Door to Page [OR 44.8, 95% CI 8.6, 234.4], Page 2 Lab [OR 5.4, 95% CI 1.9, 15.3], and Lab arrival to Reperfusion [OR 14.6 95% CI 2.5, 84.3]), but not EMS scene and transport intervals were the most important predictors D2B ≤90 minutes. CONCLUSIONS In our study, hospital process intervals (EMS activation, door to page, page to laboratory, and laboratory to reperfusion) are key covariates of rapid reperfusion for EMS STEMI patients and should be used when assessing STEMI care.
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Affiliation(s)
- Carol Lynn Clark
- Department of Emergency Medicine William Beaumont Hospital, Royal Oak, Michigan 48703, USA
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Geographic variations in percutaneous coronary interventions and coronary artery bypass graft surgery among Tennessee elders. South Med J 2011; 104:389-96. [PMID: 21886026 DOI: 10.1097/smj.0b013e3182186fdc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Coronary heart disease often presents with ST segment elevation acute myocardial infarction (STEMI). The American College of Cardiology/American Heart Association guidelines stress prompt reperfusion for STEMI. Examining geographic variations in treatment with PPCI (percutaneous primary coronary intervention) and CABG (coronary artery bypass graft) among metropolitan, micropolitan and non-micropolitan rural residents provides a descriptive basis for generating hypotheses concerning place and receipt of guidelines-based treatment. METHODS Using ICD-9 codes for STEMI and excluding beneficiaries with pre-existing MI in claims data, yielded a subset of 18,775 Tennessee Medicare beneficiaries experiencing STEMI from 1996 to 2002. The outcome variable is type of treatment, i.e., in accord (PPCI or CABG present) or not in accord (PPCI or CABG absent) with guidelines. Independent variables include type county residence, hospital volume, race, gender, and age. Analyses include cross-tabulation and logistic regression, estimating separate models by age and type of MI. RESULTS Micropolitan residents with STEMI have the lowest rates for PPCI (18.8%) versus 28.1% percent for metropolitan and 24.2% for non-micropolitan rural residents. CABG follows similar patterns at lower overall rates. Treatment at a heart center with high volume PPCI mediated the relationship between the likelihood of PPCI and place. CONCLUSION The correspondence between metropolitan and rural utilization suggests that access to a full range of treatment options and likelihood of "best practice" care is not dependent on metropolitan residence. This presents the possibility that with some policy changes, e.g., centralization of emergency heart care, the same may ultimately be true for micropolitan residents.
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Assessment of temporal trends in mortality with implementation of a statewide ST-segment elevation myocardial infarction (STEMI) regionalization program. Ann Emerg Med 2011; 59:243-252.e1. [PMID: 21862177 DOI: 10.1016/j.annemergmed.2011.07.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 07/05/2011] [Accepted: 07/13/2011] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Although regionalized care for ST-segment elevation myocardial infarction (STEMI) has improved the use of timely reperfusion therapy, its effect on patient outcomes has been difficult to assess. Our objective is to explore temporal trends in STEMI mortality with the implementation of a statewide STEMI regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments [RACE]). METHODS We compared trends in inpatient mortality among STEMI patients treated at North Carolina (NC) hospitals participating in the RACE program, relative to those not participating, using state inpatient claims data. Using Medicare claims data, we compared trends in 30-day mortality among Medicare beneficiaries in NC with those nationally. Logistic models with random effects were used to evaluate the association of the program with mortality. RESULTS From 2005 to 2007, inpatient mortality for 6,565 STEMI patients treated at NC hospitals participating in RACE decreased from 11.6% to 10.1% (risk difference -1.5%; 95% confidence interval [CI] -3.0% to 0.04%), whereas inpatient mortality among 5,850 STEMI patients treated at NC nonparticipating hospitals decreased from 10.2% to 8.6% (risk difference -1.6%; 95% CI -3.1% to 0.10%); (adjusted odds ratio 1.28; 95% CI 0.88 to 1.85 for temporal differences between groups). During the same period, 30-day STEMI mortality among Medicare beneficiaries decreased from 22.7% to 21.4% in NC (risk difference -1.28%; 95% CI -3.60% to 1.03%) and from 22.3% to 21.6% nationally (risk difference -0.71%, 95% CI -1.13% to -0.29%; adjusted odds ratio 0.99, 95% CI 0.85 to 1.15 for temporal differences between regions). CONCLUSION The initiation of a statewide STEMI collaborative care model was associated with a reduction in mortality rates according to claims data, yet these changes were similar to those seen nationally. Further study is needed to evaluate regionalized systems of STEMI care and to determine the role of claims data to evaluate population-based STEMI outcomes.
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Abstract
CONTEXT Between 1998 and 2008, the number of hospital-based emergency departments (EDs) in the United States declined, while the number of ED visits increased, particularly visits by patients who were publicly insured and uninsured. Little is known about the hospital, community, and market factors associated with ED closures. Federal law requiring EDs to treat all in need regardless of a patient's ability to pay may make EDs more vulnerable to the market forces that govern US health care. OBJECTIVE To determine hospital, community, and market factors associated with ED closures. DESIGN Emergency department and hospital organizational information from 1990 through 2009 was acquired from the American Hospital Association (AHA) Annual Surveys (annual response rates ranging from 84%-92%) and merged with hospital financial and payer mix information available through 2007 from Medicare hospital cost reports. We evaluated 3 sets of risk factors: hospital characteristics (safety net [as defined by hospitals caring for more than double their Medicaid share of discharges compared with other hospitals within a 15-mile radius], ownership, teaching status, system membership, ED size, case mix), county population demographics (race, poverty, uninsurance, elderly), and market factors (ownership mix, profit margin, location in a competitive market, presence of other EDs). SETTING All general, acute, nonrural, short-stay hospitals in the United States with an operating ED anytime from 1990-2009. MAIN OUTCOME MEASURE Closure of an ED during the study period. RESULTS From 1990 to 2009, the number of hospitals with EDs in nonrural areas declined from 2446 to 1779, with 1041 EDs closing and 374 hospitals opening EDs. Based on analysis of 2814 urban acute-care hospitals, constituting 36,335 hospital-year observations over an 18-year study interval (1990-2007), for-profit hospitals and those with low profit margins were more likely to close than their counterparts (cumulative hazard rate based on bivariate model, 26% vs 16%; hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.5-2.1, and 36% vs 18%; HR, 1.9; 95% CI, 1.6-2.3, respectively). Hospitals in more competitive markets had a significantly higher risk of closing their EDs (34% vs 17%; HR, 1.3; 95% CI, 1.1-1.6), as did safety-net hospitals (10% vs 6%; HR, 1.4; 95% CI, 1.1-1.7) and those serving a higher share of populations in poverty (37% vs 31%; HR, 1.4; 95% CI, 1.1-1.7). CONCLUSION From 1990 to 2009, the number of hospital EDs in nonrural areas declined by 27%, with for-profit ownership, location in a competitive market, safety-net status, and low profit margin associated with increased risk of ED closure.
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Affiliation(s)
- Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, CA, USA.
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Hsia RY, Carr BG. Measuring emergency care systems: the path forward. Ann Emerg Med 2011; 58:267-9. [PMID: 21507525 DOI: 10.1016/j.annemergmed.2011.03.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 03/21/2011] [Accepted: 03/21/2011] [Indexed: 11/29/2022]
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Pilgrim R, Hilton JA, Carrier E, Pines JM, Hufstetler G, Thorby S, Milling TJ, Cesta B, Hsia RY. Research priorities for administrative challenges of integrated networks of care. Acad Emerg Med 2010; 17:1330-6. [PMID: 21122015 DOI: 10.1111/j.1553-2712.2010.00934.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In 2006, the Institute of Medicine (IOM) advanced the concept of "coordinated, regionalized, and accountable emergency care systems" to address significant problems with the delivery of emergency medical care in the United States. Achieving this vision requires the thoughtful implementation of well-aligned, system-level structures and processes that enhance access to emergency care and improve patient outcomes at a sustainable cost. Currently, the delivery of emergency medical care is supported by numerous administrative systems, including economic; reimbursement; legal and regulatory structures; licensure, credentialing, and accreditation processes; medicolegal systems; and quality reporting mechanisms. In addition, many regionalized systems may not optimize patient outcomes because of current administrative barriers that make it difficult for providers to deliver the best care. However, certain administrative barriers may also threaten the sustainability of integration efforts or prevent them altogether. This article identifies significant administrative challenges to integrating networks of emergency care in four specific areas: reimbursement, medical-legal, quality reporting mechanisms, and regulatory aspects. The authors propose a research agenda for indentifying optimal approaches that support consistent access to quality emergency care with improved outcomes for patients, at a sustainable cost. Researching administrative challenges will involve careful examination of the numerous natural experiments in the recent past and will be crucial to understand the impact as we embark on a new era of health reform.
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Yeh RW, Sidney S, Chandra M, Sorel M, Selby JV, Go AS. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med 2010; 362:2155-65. [PMID: 20558366 DOI: 10.1056/nejmoa0908610] [Citation(s) in RCA: 1239] [Impact Index Per Article: 88.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Few studies have characterized recent population trends in the incidence and outcomes of myocardial infarction. METHODS We identified patients 30 years of age or older in a large, diverse, community-based population who were hospitalized for incident myocardial infarction between 1999 and 2008. Age- and sex-adjusted incidence rates were calculated for myocardial infarction overall and separately for ST-segment elevation and non-ST-segment elevation myocardial infarction. Patient characteristics, outpatient medications, and cardiac biomarker levels during hospitalization were identified from health plan databases, and 30-day mortality was ascertained from administrative databases, state death data, and Social Security Administration files. RESULTS We identified 46,086 hospitalizations for myocardial infarctions during 18,691,131 person-years of follow-up from 1999 to 2008. The age- and sex-adjusted incidence of myocardial infarction increased from 274 cases per 100,000 person-years in 1999 to 287 cases per 100,000 person-years in 2000, and it decreased each year thereafter, to 208 cases per 100,000 person-years in 2008, representing a 24% relative decrease over the study period. The age- and sex-adjusted incidence of ST-segment elevation myocardial infarction decreased throughout the study period (from 133 cases per 100,000 person-years in 1999 to 50 cases per 100,000 person-years in 2008, P<0.001 for linear trend). Thirty-day mortality was significantly lower in 2008 than in 1999 (adjusted odds ratio, 0.76; 95% confidence interval, 0.65 to 0.89). CONCLUSIONS Within a large community-based population, the incidence of myocardial infarction decreased significantly after 2000, and the incidence of ST-segment elevation myocardial infarction decreased markedly after 1999. Reductions in short-term case fatality rates for myocardial infarction appear to be driven, in part, by a decrease in the incidence of ST-segment elevation myocardial infarction and a lower rate of death after non-ST-segment elevation myocardial infarction.
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Affiliation(s)
- Robert W Yeh
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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