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Stopyra JP, Snavely AC, Ashburn NP, Supples MW, Brown WM, Miller CD, Mahler SA. Rural EMS STEMI Patients - Why the Delay to PCI? PREHOSP EMERG CARE 2024:1-8. [PMID: 38235978 DOI: 10.1080/10903127.2024.2305967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/13/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND The objective of this study is to identify patient and EMS agency factors associated with timely reperfusion of patients with ST-elevation myocardial infarction (STEMI). METHODS We conducted a cohort study of adult patients (≥18 years old) with STEMI activations from 2016 to 2020. Data was obtained from a regional STEMI registry, which included eight rural county EMS agencies and three North Carolina percutaneous coronary intervention (PCI) centers. On each patient, prehospital and in-hospital time intervals were abstracted. The primary outcome was the ability to achieve the 90-minute EMS FMC to PCI time goal (yes vs. no). We used generalized estimating equations accounting for within-agency clustering to evaluate the association between patient and agency factors and meeting first medical contact (FMC) to PCI time goal while accounting for clustering within the agency. RESULTS Among 365 rural STEMI patients 30.1% were female (110/365) with a mean age of 62.5 ± 12.7 years. PCI was performed within the time goal in 60.5% (221/365) of encounters. The FMC to PCI time goal was met in 45.5% (50/110) of women vs 69.8% (178/255) of men (p < 0.001). The median PCI center activation time was 12 min (IQR 7-19) in the group that received PCI within the time goal compared to 21 min (IQR 10-37) in the cohort that did not. After adjusting for loaded mileage and other clinical variables (e.g., pulse rate, hypertension etc.), the male sex was associated with an improved chance of meeting the goal of FMC to PCI (aOR: 2.94; 95% CI 2.11-4.10) compared to the female sex. CONCLUSION Nearly 40% of rural STEMI patients transported by EMS failed to receive FMC to PCI within 90 min. Women were less likely than men to receive reperfusion within the time goal, which represents an important health care disparity.
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Affiliation(s)
- Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael W Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - W Mark Brown
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Chadwick D Miller
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
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2
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Stopyra JP, Snavely AC, Ashburn NP, Supples MW, Miller CD, Mahler SA. Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST-elevation myocardial infarction. Acad Emerg Med 2023; 30:1101-1109. [PMID: 37567785 PMCID: PMC10830062 DOI: 10.1111/acem.14787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/24/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND ST-elevation myocardial infarction (STEMI) guidelines recommend an emergency medical services (EMS) first medical contact (FMC) to percutaneous coronary intervention (PCI) time of ≤90 min. The primary objective of this study was to evaluate the association between FMC to PCI time and mortality in rural STEMI patients. METHODS We conducted a cohort study of patients ≥18 years old with STEMI activations from January 2016 to March 2020. Data were obtained from a rural North Carolina Regional STEMI Data Registry, which included eight rural EMS agencies and three PCI centers, the National Cardiovascular Data Registry, and the EMS electronic health record. Prehospital and in-hospital time intervals were digitally abstracted. The outcome of index hospitalization mortality was compared between patients who did and did not meet FMC to PCI time goal using Fisher's exact tests. Negative predictive value (NPV) for index hospitalization death was calculated with 95% confidence intervals (CIs). A receiver operating characteristic curve was constructed and an optimal FMC to PCI time goal was identified by maximizing NPV to prevent index hospitalization death. RESULTS Among 365 rural EMS STEMI patients, 30.1% (110/365) were female with a mean ± SD age of 62.5 ± 12.7 years. PCI was performed within the 90-min time goal in 60.5% (221/365) of patients. Among these patients, 3% (11/365) died during initial STEMI hospitalization, with 1.4% (3/221) mortality in the group that met the 90-minute time goal compared to 5.6% (8/144) in patients exceeding the time goal (p = 0.03). Meeting the 90-min time goal yielded a 98.6% (95% CI 96.1%-99.7%) NPV for index death. A 78-min FMC to PCI time was the optimal cut point, yielding a NPV for index mortality of 99.3% (95% CI 96.1%-100%). CONCLUSIONS Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 min.
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Affiliation(s)
- Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael W. Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Chadwick D. Miller
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Kamin Mukaz D, Cushman M. Percutaneous Coronary Intervention in Acute Myocardial Infarction: Community Wealth Matters. J Am Heart Assoc 2023; 12:e031415. [PMID: 37646210 PMCID: PMC10547354 DOI: 10.1161/jaha.123.031415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Debora Kamin Mukaz
- Department of MedicineLarner College of Medicine, University of VermontBurlingtonVTUSA
| | - Mary Cushman
- Department of MedicineLarner College of Medicine, University of VermontBurlingtonVTUSA
- Department of Pathology and Laboratory MedicineLarner College of Medicine, University of VermontBurlingtonVTUSA
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Shen Y, Sarkar N, Hsia RY. Differential Treatment and Outcomes for Patients With Heart Attacks in Advantaged and Disadvantaged Communities. J Am Heart Assoc 2023; 12:e030506. [PMID: 37646213 PMCID: PMC10547340 DOI: 10.1161/jaha.122.030506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/15/2023] [Indexed: 09/01/2023]
Abstract
Background Racially and ethnically minoritized groups, people with lower income, and rural communities have worse access to percutaneous coronary intervention (PCI) than their counterparts, but PCI hospitals have preferentially opened in wealthier areas. Our study analyzed disparities in PCI access, treatment, and outcomes for patients with acute myocardial infarction based on the census-derived Area Deprivation Index. Methods and Results We obtained patient-level data on 629 419 patients with acute myocardial infarction in California between January 1, 2006 and December 31, 2020. We linked patient data with population characteristics and geographic coordinates, and categorized communities into 5 groups based on the share of the population in low or high Area Deprivation Index neighborhoods to identify differences in PCI access, treatment, and outcomes based on community status. Risk-adjusted models showed that patients in the most advantaged communities had 20% and 15% greater likelihoods of receiving same-day PCI and PCI during the hospitalization, respectively, compared with patients in the most disadvantaged communities. Patients in the most advantaged communities also had 19% and 16% lower 30-day and 1-year mortality rates, respectively, compared with the most disadvantaged, and a 15% lower 30-day readmission rate. No statistically significant differences in admission to a PCI hospital were observed between communities. Conclusions Patients in disadvantaged communities had lower chances of receiving timely PCI and a greater risk of mortality and readmission compared with those in more advantaged communities. These findings suggest a need for targeted interventions to influence where cardiac services exist and who has access to them.
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Affiliation(s)
- Yu‐Chu Shen
- Department of Defense ManagementNaval Postgraduate SchoolMontereyCAUSA
- National Bureau of Economic ResearchCambridgeMAUSA
| | | | - Renee Y. Hsia
- Department of Emergency MedicineUniversity of California, San FranciscoCAUSA
- Philip R. Lee Institute for Health Policy StudiesUniversity of California, San FranciscoCAUSA
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Osho A, Fernandes MF, Poudel R, de Lemos J, Hong H, Zhao J, Li S, Thomas K, Kikuchi DS, Zegre-Hemsey J, Ibrahim N, Shah NS, Hollowell L, Tamis-Holland J, Granger CB, Cohen M, Henry T, Jacobs AK, Jollis JG, Yancy CW, Goyal A. Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry. Circulation 2023; 148:229-240. [PMID: 37459415 DOI: 10.1161/circulationaha.123.065512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/13/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain. METHODS We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines-Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to-percutaneous coronary intervention time within 90 minutes; and first medical contact-to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients' county of residence. RESULTS Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact-to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12-1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74-1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82-1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85-1.09]). CONCLUSIONS Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.
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Affiliation(s)
- Asishana Osho
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston (A.O.)
| | | | - Ram Poudel
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - James de Lemos
- University of Texas Southwestern Medical Center, Dallas (J.d.L.)
| | - Haoyun Hong
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Juan Zhao
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Shen Li
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Kathie Thomas
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | - Daniel S Kikuchi
- Osler Medical Residency, Johns Hopkins Hospital, Baltimore, MD (D.S.K.)
| | | | - Nasrien Ibrahim
- Harvard T.H. Chan School of Public Health, Boston, MA (N.I.)
| | - Nilay S Shah
- Department of Medicine, Division of Cardiology, Northwestern University Medical School, Chicago, IL (N.S.S., C.W.Y.)
| | - Lori Hollowell
- American Heart Association, Dallas, TX (R.P., H.H., J.Z., S.L., K.T., L.H.)
| | | | | | | | - Timothy Henry
- The Christ Hospital Heart and Vascular Institute, Cincinnati, OH (T.H., J.G.J.)
| | | | - James G Jollis
- The Christ Hospital Heart and Vascular Institute, Cincinnati, OH (T.H., J.G.J.)
| | - Clyde W Yancy
- Department of Medicine, Division of Cardiology, Northwestern University Medical School, Chicago, IL (N.S.S., C.W.Y.)
| | - Abhinav Goyal
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.G.)
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Shen YC, Krumholz HM, Hsia RY. Do PCI Facility Openings and Closures Affect AMI Outcomes Differently in High- vs Average-Capacity Markets? JACC Cardiovasc Interv 2023; 16:1129-1140. [PMID: 37225284 PMCID: PMC10229059 DOI: 10.1016/j.jcin.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Disparities in access to percutaneous coronary intervention (PCI) for patients with acute myocardial infarction may result from openings and closures of PCI-providing hospitals, potentially leading to low hospital PCI volume, which is associated with poor outcomes. OBJECTIVES The authors sought to determine whether openings and closures of PCI hospitals have differentially impacted patient health outcomes in high- vs average-capacity PCI markets. METHODS In this retrospective cohort study, the authors identified PCI hospital availability within a 15-minute driving time of zip code communities. The authors categorized communities by baseline PCI capacity and identified changes in outcomes associated with PCI-providing hospital openings and closures using community fixed-effects regression models. RESULTS From 2006 to 2017, 20% and 16% of patients in average- and high-capacity markets, respectively, experienced a PCI hospital opening within a 15-minute drive. In average-capacity markets, openings were associated with a 2.6 percentage point decrease in admission to a high-volume PCI facility; high-capacity markets saw an 11.6 percentage point decrease. After an opening, patients in average-capacity markets experienced a 5.5% and 7.6% relative increase in likelihood of same-day and in-hospital revascularization, respectively, as well as a 2.5% decrease in mortality. PCI hospital closures were associated with a 10.4% relative increase in admission to high-volume PCI hospitals and a 1.4 percentage point decrease in receipt of same-day PCI. There was no change observed in high-capacity PCI markets. CONCLUSIONS After openings, patients in average-capacity markets derived significant benefits, whereas those in high-capacity markets did not. This suggests that past a certain threshold, facility opening does not improve access and health outcomes.
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Affiliation(s)
- Yu-Chu Shen
- Naval Postgraduate School, Monterey, California, USA; National Bureau of Economic Research, Cambridge Massachusetts, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, California, USA; Philip R. Lee Institute for Health Policy Studies, University of California-San Francisco, San Francisco, California, USA.
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7
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Levy EI, Monteiro A, Waqas M, Siddiqui AH. Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities. Neurosurgery 2023; 92:3-9. [PMID: 36519855 DOI: 10.1227/neu.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/25/2022] [Indexed: 12/23/2022] Open
Abstract
Mechanical thrombectomy (MT) became the "gold-standard" treatment for most patients with acute ischemic stroke due to anterior circulation large vessel occlusion. With such a remarkable paradigm shift, it is important that this modality of treatment becomes widely and homogeneously available throughout the United States and other countries. Although the time window for MT is large (24 hours in selected patients), time is still a major determinant of outcome. Several variables are involved in achieving timely access of MT for the majority of the population: prehospital management systems, transportation models, in-hospital workflow organization, accreditation and infrastructure of centers, training of neurointervention professionals, and geographic distribution of centers. The current situation in the United States regarding MT access is marked by geographic and socioeconomic disparities. We provide an overview of current challenges and solutions in achieving more universal access to MT for the population.
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Affiliation(s)
- Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
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8
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Siasos G, Tsigkou V, Bletsa E, Stampouloglou PK, Oikonomou E, Kalogeras K, Katsarou O, Pesiridis T, Vavuranakis M, Tousoulis D. Antithrombotic Treatment in Coronary Artery Disease. Curr Pharm Des 2023; 29:2764-2779. [PMID: 37644793 DOI: 10.2174/1381612829666230830105750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/16/2023] [Accepted: 07/20/2023] [Indexed: 08/31/2023]
Abstract
Coronary artery disease exhibits growing mortality and morbidity worldwide despite the advances in pharmacotherapy and coronary intervention. Coronary artery disease is classified in the acute coronary syndromes and chronic coronary syndromes according to the most recent guidelines of the European Society of Cardiology. Antithrombotic treatment is the cornerstone of therapy in coronary artery disease due to the involvement of atherothrombosis in the pathophysiology of the disease. Administration of antiplatelet agents, anticoagulants and fibrinolytics reduce ischemic risk, which is amplified early post-acute coronary syndromes or post percutaneous coronary intervention; though, antithrombotic treatment increases the risk for bleeding. The balance between ischemic and bleeding risk is difficult to achieve and is affected by patient characteristics, procedural parameters, concomitant medications and pharmacologic characteristics of the antithrombotic agents. Several pharmacological strategies have been evaluated in patients with coronary artery disease, such as the effectiveness and safety of antithrombotic agents, optimal dual antiplatelet treatment schemes and duration, aspirin de-escalation strategies of dual antiplatelet regimens, dual inhibition pathway strategies as well as triple antithrombotic therapy. Future studies are needed in order to investigate the gaps in our knowledge, including special populations.
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Affiliation(s)
- Gerasimos Siasos
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
- Cardiovascular Division, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Vasiliki Tsigkou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Evanthia Bletsa
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Panagiota K Stampouloglou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Evangelos Oikonomou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Konstantinos Kalogeras
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Ourania Katsarou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Theodoros Pesiridis
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Manolis Vavuranakis
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Dimitris Tousoulis
- Department of Cardiology, School of Medicine, 'Hippokration' General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Khalid N, Ahmad SA. Disparities in Urgent Cardiovascular Care in the United States. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 46:10-11. [PMID: 36307362 DOI: 10.1016/j.carrev.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Nauman Khalid
- Section of Interventional Cardiology, St. Francis Medical Center, Monroe, LA, United States of America.
| | - Sarah Aftab Ahmad
- Section of Cardiothoracic Surgery, St. Francis Medical Center, Monroe, LA, United States of America
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10
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Wang C, Lindquist K, Krumholz H, Hsia RY. Trends in the likelihood of receiving percutaneous coronary intervention in a low-volume hospital and disparities by sociodemographic communities. PLoS One 2023; 18:e0279905. [PMID: 36652416 PMCID: PMC9847957 DOI: 10.1371/journal.pone.0279905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/17/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Over the past two decades, percutaneous coronary intervention (PCI) capacity has increased while coronary artery disease has decreased, potentially lowering per-hospital PCI volumes, which is associated with less favorable patient outcomes. Trends in the likelihood of receiving PCI in a low-volume center have not been well-documented, and it is unknown whether certain socioeconomic factors are associated with a greater risk of PCI in a low-volume facility. Our study aims to determine the likelihood of being treated in a low-volume PCI center over time and if this likelihood differs by sociodemographic factors. METHODS We conducted a retrospective cohort study of 374,066 hospitalized patients in California receiving PCI from January 1, 2010, to December 31, 2018. Our primary outcome was the likelihood of PCI discharges at a low-volume hospital (<150 PCI/year), and secondary outcomes included whether this likelihood varied across different sociodemographic groups and across low-volume hospitals stratified by high or low ZIP code median income. RESULTS The proportion of PCI discharges from low-volume hospitals increased from 5.4% to 11.0% over the study period. Patients of all sociodemographic groups considered were more likely to visit low-volume hospitals over time (P<0.001). Latinx patients were more likely to receive PCI at a low-volume hospital compared with non-Latinx White in 2010 with a 166% higher gap in 2018 (unadjusted proportions). The gaps in relative risk (RR) between Black, Latinx and Asian patients versus non-Latinx white increased over time, whereas the gap between private versus public/no insurance, and high versus low income decreased (interaction P<0.001). In low-income ZIP codes, patients with Medicaid were less likely to visit low-volume hospitals than patients with private insurance in 2010; however, this gap reversed and increased by 500% in 2018. Patients with low income were more likely to receive PCI at low-volume hospitals relative to patients with high income in all study years. CONCLUSIONS The likelihood of receiving PCI at low-volume hospitals has increased across all race/ethnicity, insurance, and income groups over time; however, this increase has not occurred evenly across all sociodemographic groups.
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Affiliation(s)
- Christina Wang
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Karla Lindquist
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Harlan Krumholz
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, United States of America
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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11
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Cai M, Liu E, Bai P, Zhang N, Wang S, Li W, Lin H, Lin X. The Chasm in Percutaneous Coronary Intervention and In-Hospital Mortality Rates Among Acute Myocardial Infarction Patients in Rural and Urban Hospitals in China: A Mediation Analysis. Int J Public Health 2022; 67:1604846. [PMID: 35872707 PMCID: PMC9302370 DOI: 10.3389/ijph.2022.1604846] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: To determine to what extent the inequality in the ability to provide percutaneous coronary intervention (PCI) translates into outcomes for AMI patients in China.Methods: We identified 82,677 patients who had primary diagnoses of AMI and were hospitalized in Shanxi Province, China, between 2013 and 2017. We applied logistic regressions with inverse probability weighting based on propensity scores and mediation analyses to examine the association of hospital rurality with in-hospital mortality and the potential mediating effects of PCI.Results: In multivariate models where PCI was not adjusted for, rural hospitals were associated with a significantly higher risk of in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.03–1.37). However, this association was nullified (OR: 0.94, 95% CI: 0.81–1.08) when PCI was included as a covariate. Mediation analyses revealed that PCI significantly mediated 132.3% (95% CI: 104.1–256.6%) of the effect of hospital rurality on in-hospital mortality. The direct effect of hospital rurality on in-hospital mortality was insignificant.Conclusion: The results highlight the need to improve rural hospitals’ infrastructure and address the inequalities of treatments and outcomes in rural and urban hospitals.
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Affiliation(s)
- Miao Cai
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Echu Liu
- College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, United States
| | - Peng Bai
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nan Zhang
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Provincial Clinical Research Center for Diabetes and Metabolic Disorder, Wuhan, China
| | - Siyu Wang
- Center for Genome Sciences and Systems Biology, School of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Wei Li
- Department of Data Science, Zhejiang University of Finance and Economics Dongfang College, Haining, China
| | - Hualiang Lin
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Xiaojun Lin
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
- *Correspondence: Xiaojun Lin,
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12
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Functional Evaluation of Coronary Stenosis: is Quantitative Flow Ratio a Step Forward? COR ET VASA 2022. [DOI: 10.33678/cor.2022.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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13
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Stopyra JP, Crowe RP, Snavely AC, Supples MW, Page N, Smith Z, Ashburn NP, Foley K, Miller CD, Mahler SA. Prehospital Time Disparities for Rural Patients with Suspected STEMI. PREHOSP EMERG CARE 2022; 27:488-495. [PMID: 35380911 PMCID: PMC9606141 DOI: 10.1080/10903127.2022.2061660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Rural patients with ST-elevation myocardial infarction (STEMI) may be less likely to receive prompt reperfusion therapy. This study's primary objective was to compare rural versus urban time intervals among a national cohort of prehospital patients with STEMI. METHODS The ESO Data Collaborative (Austin, TX), containing records from 1,366 emergency medical services agencies, was queried for adult 9-1-1 responses with suspected STEMI from 1/1/2018-12/31/2019. The scene address for each encounter was classified as either urban or rural using the 2010 US Census Urban Area Zip Code Tabulation Area relationship. The primary outcome was total EMS interval (9-1-1 call to hospital arrival); a key secondary outcome was the proportion of responses that had EMS intervals under 60 minutes. Generalized estimating equations were used to determine whether rural versus urban differences in interval outcomes occurred when adjusting for loaded mileage (distance from scene to hospital) and patient and clinical encounter characteristics. RESULTS Of 15,915,027 adult 9-1-1 transports, 23,655 records with suspected STEMI were included in the analysis. Most responses (91.6%, n = 21,661) occurred in urban settings. Median EMS interval was 37.6 minutes (IQR 30.0-48.0) in urban settings compared to 57.0 minutes (IQR 46.5-70.7) in rural settings (p < 0.01). Urban responses more frequently had EMS intervals <60 minutes (89.5%, n = 19,130), compared to rural responses (55.5%, n = 1,100, p < 0.01). After adjusting for loaded mileage, age, sex, race/ethnicity, abnormal vital signs, pain assessment, aspirin administration, and IV/IO attempt, rural location was associated with a 5.8 (95%CI 4.2-7.4) minute longer EMS interval than urban, and rural location was associated with a reduced chance of achieving EMS interval < 60 minutes (OR 0.40; 95%CI 0.33-0.49) as compared to urban location. CONCLUSION In this large national sample, rural location was associated with significantly longer EMS interval for patients with suspected STEMI, even after accounting for loaded mileage.
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Affiliation(s)
- Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine (WFSOM) Winston-Salem, NC
| | | | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine (WFSOM) Winston-Salem, NC
- Department of Biostatistics and Data Science, WFSOM, Winston-Salem, NC
| | - Michael W. Supples
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Nathan Page
- Department of Emergency Medicine, Wake Forest School of Medicine (WFSOM) Winston-Salem, NC
| | - Zachary Smith
- Department of Emergency Medicine, Wake Forest School of Medicine (WFSOM) Winston-Salem, NC
| | - Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine (WFSOM) Winston-Salem, NC
| | - Kristie Foley
- Implementation Science and Epidemiology and Prevention, WFSOM, Winston-Salem, NC
| | - Chadwick D. Miller
- Department of Emergency Medicine, Wake Forest School of Medicine (WFSOM) Winston-Salem, NC
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine (WFSOM) Winston-Salem, NC
- Implementation Science and Epidemiology and Prevention, WFSOM, Winston-Salem, NC
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14
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Fanaroff AC, Nathan AS. Percutaneous Coronary Intervention in Acute Coronary Syndrome and Cardiogenic Shock: Ensuring Access While Maintaining Quality. JACC Cardiovasc Interv 2022; 15:887-889. [PMID: 35450688 DOI: 10.1016/j.jcin.2022.02.011] [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] [Received: 01/26/2022] [Accepted: 02/01/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania USA.
| | - Ashwin S Nathan
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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15
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Hsia RY, Zagorov S. Structural Discrimination in Emergency Care: How a Sick System Affects Us All. MED (NEW YORK, N.Y.) 2022; 3:98-103. [PMID: 35224522 PMCID: PMC8880827 DOI: 10.1016/j.medj.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Drawing on evidence of socioeconomic disparities in emergency care, we show how structural discrimination is the most pervasive driver of these disparities, largely because of an inequitable distribution of healthcare services and unequal benefits derived from scientific advancement. We analyze how the market-based healthcare system in the U.S. has created a scenario in which the allocation of emergency care resources does not match community demand for emergency care, resulting in disproportionately poor access, treatment, and outcomes among historically underserved populations. Without fundamental reform, there is little hope for decreasing the health outcome gaps between the "haves" and "have-nots" in the United States.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco,Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco,San Francisco General Hospital and Trauma Center,Correspondence:
| | - Stefany Zagorov
- Department of Emergency Medicine, University of California, San Francisco
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16
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Jacobs AK, Ali MJ, Best PJ, Bieniarz MC, Bufalino VJ, French WJ, Henry TD, Hollowell L, Jauch EC, Kurz MC, Levy M, Patel P, Spier T, Stone RH, Tataris KL, Thomas RJ, Zègre-Hemsey JK. Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association. Circulation 2021; 144:e310-e327. [PMID: 34641735 DOI: 10.1161/cir.0000000000001025] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The introduction of Mission: Lifeline significantly increased timely access to percutaneous coronary intervention for patients with ST-segment-elevation myocardial infarction (STEMI). In the years since, morbidity and mortality rates have declined, and research has led to significant developments that have broadened our concept of the STEMI system of care. However, significant barriers and opportunities remain. From community education to 9-1-1 activation and emergency medical services triage and from emergency department and interfacility transfer protocols to postacute care, each critical juncture presents unique challenges for the optimal care of patients with STEMI. This policy statement sets forth recommendations for how the ideal STEMI system of care should be designed and implemented to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness.
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17
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Chang KY, Chiu N, Aggarwal R. In-Hospital Mortality for Inpatient Percutaneous Coronary Interventions in the United States. Am J Cardiol 2021; 159:30-35. [PMID: 34503823 DOI: 10.1016/j.amjcard.2021.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/18/2022]
Abstract
Cardiovascular mortality is substantially higher in rural communities compared with urban communities. Understanding if disparities in inpatient percutaneous coronary intervention (PCI) persist in the United States will help inform initiatives to improve cardiovascular health. Of the more than 7 million hospitalizations in the National Inpatient Sample (2016), we identified 80,793 unweighted hospitalizations for PCI using ICD-10 procedure codes. Using survey weights, these hospitalizations projected 371,040 US admissions for inpatient PCI. For the primary analysis, we determined the association between hospital urban-rural designation and in-hospital mortality after inpatient PCI. In the secondary analysis, we evaluated the association between teaching status and this outcome. Multivariable logistic regression models, adjusted for multiple risk factors and patient characteristics, were used. Of the 371,430 hospitalizations for inpatient PCI, there were 108.9 (±2.2) admissions per 100,000 US population from urban hospitals and 152.9 (±6.3) from rural hospitals. Of the urban hospitals, there were 77.7 (±1.9) admissions per 100,000 US population at teaching hospitals (71.7%) and 30.7 (±1.0) at urban nonteaching hospitals (28.3%). In-hospital mortality did not differ between urban and rural hospitals (1.8% urban vs 1.9% rural, adjusted odds ratio for rural compared with urban: 1.15 [95% confidence interval 0.98, 1.34], p = 0.08). In urban hospitals, however, in-hospital mortality was higher in nonteaching hospitals than in teaching hospitals (2.0% nonteaching vs 1.7% teaching, adjusted odds ratio for teaching compared with nonteaching: 1.17 [95% confidence interval 1.01, 1.36], p = 0.04). In conclusion, in-hospital mortality rates after inpatient PCI were similar between urban and rural hospitals in the United States. However, among urban hospitals, nonteaching hospitals had higher rates of in-hospital mortality after PCI. In conclusion, solutions to address disparities for inpatient PCI outcomes between teaching and nonteaching hospitals are needed.
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Affiliation(s)
- Katie Y Chang
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nicholas Chiu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Rahul Aggarwal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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18
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Morris NA, Mazzeffi M, McArdle P, May TL, Waldrop G, Perman SM, Burke JF, Bradley SM, Agarwal S, Figueroa JF, Badjatia N. Hispanic/Latino-Serving Hospitals Provide Less Targeted Temperature Management Following Out-of-Hospital Cardiac Arrest. J Am Heart Assoc 2021; 10:e017773. [PMID: 34743562 PMCID: PMC9075225 DOI: 10.1161/jaha.121.023934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Variation exists in outcomes following out-of-hospital cardiac arrest, but whether racial and ethnic disparities exist in postarrest provision of targeted temperature management (TTM) is unknown. Methods and Results We performed a retrospective analysis of a prospectively collected cohort of patients who survived to admission following out-of-hospital cardiac arrest from the Cardiac Arrest Registry to Enhance Survival, whose catchment area represents ≈50% of the United States from 2013 to 2019. Our primary exposure was race or ethnicity and primary outcome was utilization of TTM. We built a mixed-effects model with both state of arrest and admitting hospital modeled as random intercepts to account for clustering. Among 96 695 patients (24.6% Black patients, 8.0% Hispanic/Latino patients, and 63.4% White patients), a smaller percentage of Hispanic/Latino patients received TTM than Black or White patients (37.5% versus 45.0% versus 43.3%, P<0.001) following out-of-hospital cardiac arrest. In the mixed-effects model, Black patients (odds ratio [OR], 1.153 [95% CI, 1.102-1.207], P<0.001) and Hispanic/Latino patients (OR, 1.086 [95% CI, 1.017-1.159], P<0.001) were slightly more likely to receive TTM compared with White patients, perhaps because of worse neurological status on admission. We did find community- level disparity because Hispanic/Latino-serving hospitals (defined as the top decile of hospitals that cared for the highest proportion of Hispanic/Latino patients) provided less TTM (OR, 0.587 [95% CI, 0.474-0.742], P<0.001). Conclusions Reassuringly, we did not find evidence of intrahospital or interpersonal racial or ethnic disparity in the provision of TTM. However, we did find interhospital, community-level disparity. Hispanic/Latino-serving hospitals provided less guideline-recommended TTM after out-of-hospital cardiac arrest.
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Affiliation(s)
- Nicholas A Morris
- Department of Neurology Program in Trauma University of Maryland School of Medicine Baltimore MD
| | - Michael Mazzeffi
- Department of Anesthesiology University of Maryland School of Medicine Baltimore MD
| | - Patrick McArdle
- Departments of Medicine and Epidemiology & Public Health University of Maryland School of Medicine Baltimore MD
| | - Teresa L May
- Department of Critical Care Services Maine Medical Center Portland ME
| | - Greer Waldrop
- Department of Neurology Columbia University Vagelos College of Physicians and Surgeons New York NY
| | - Sarah M Perman
- Department of Emergency Medicine Department of Medicine Center for Women's Health Research University of Colorado School of Medicine Aurora CO
| | - James F Burke
- Department of Neurology University of Michigan Ann Arbor MI
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis MN
| | - Sachin Agarwal
- Department of Neurology Columbia University Vagelos College of Physicians and Surgeons New York NY
| | - Jose F Figueroa
- Department of Health Policy & Management Harvard T.H. Chan School of Public Health Boston MA
| | - Neeraj Badjatia
- Department of Neurology Program in Trauma University of Maryland School of Medicine Baltimore MD
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19
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Ahuja KR, Saad AM, Nazir S, Ariss RW, Shekhar S, Isogai T, Kassis N, Mahmood A, Sheikh M, Kapadia SR. Trends in Clinical Characteristics and Outcomes in ST-Elevation Myocardial Infarction Hospitalizations in the United States, 2002-2016. Curr Probl Cardiol 2021; 47:101005. [PMID: 34627825 DOI: 10.1016/j.cpcardiol.2021.101005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 01/16/2023]
Abstract
ST-segment Elevation Myocardial Infarction (STEMI) remains a major modern-day public health problem. We aimed to assess the demographic trends in STEMI related hospitalizations in the United States over a period of fifteen years. The nationwide inpatient sample was queried to obtain information of patients hospitalized with STEMI from January 1, 2002, to December 31, 2016. Annual hospitalization rates were calculated and annual percentage change (APC) was evaluated using regression analysis. A total of 4,121,155 eligible patients were included in this analysis. Overall, the total number of STEMI hospitalization decreased from 421,043 in 2002 to 208,510 in 2016 (P-trend <0.01). With the decreasing trend, the rate was relatively higher among males as compared to females, whites as compared to non-whites, and lower as compared to high socioeconomic status (SES). The rate of PCI in STEMI patients increased from 32.8% in 2002 to 67.8% in 2016 (APC = 5.392%, 95% CI [4.384-6.411], P < 0.001), but was higher among males as compared to females, urban as compared to rural hospitals and higher as compared to lower SES. In-hospital mortality decreased from 11% in 2002 to 10.5% in 2016 (APC = -0.771%, 95% CI [-1.230 to -0.311], P = 0.003), but remained higher among females, rural hospitals and low SES as compared to their correspondent groups. Among STEMI patients, the prevalence of individual comorbidities was noted to be increasing over the study period. Although there has been a declining trend in the number of STEMI hospitalizations, patients with modifiable risk factors presenting with STEMI has been on the rise. Females, rural communities and lower SES groups need special attention because of greater vulnerability.
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Affiliation(s)
- Keerat Rai Ahuja
- Department of Cardiovascular Medicine, Reading Hospital Tower Health, West Reading, PA
| | - Anas M Saad
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Salik Nazir
- Department of Cardiovascular Medicine, University of Toledo, Toledo, OH
| | - Robert W Ariss
- Department of Cardiovascular Medicine, University of Toledo, Toledo, OH
| | - Shashank Shekhar
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Toshiaki Isogai
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Nicholas Kassis
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Asif Mahmood
- Department of Medicine, University of Toledo, Toledo, OH
| | - Mujeeb Sheikh
- ProMedica Heart Institute, ProMedica Toledo Hospital, Toledo, OH
| | - Samir R Kapadia
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH.
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20
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Walters D, Mahmud E. Thrombolytic Therapy for ST-Elevation Myocardial Infarction Presenting to non-Percutaneous Coronary Intervention Centers During the COVID-19 Crisis. Curr Cardiol Rep 2021; 23:152. [PMID: 34585300 PMCID: PMC8478007 DOI: 10.1007/s11886-021-01576-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/05/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to offer a discussion on the existing data for the use of thrombolytic therapy for the treatment of ST-elevation myocardial infarction (STEMI) as well to present an evidence-based approach regarding the treatment for STEMI patients presenting to non-percutaneous coronary intervention (PCI)-capable hospitals during the ongoing COVID-19 pandemic. RECENT FINDINGS There have been tremendous advances in the care of STEMI patients over the past two decades with primary (PCI) being the standard of care. However, many hospitals do not have interventional cardiology services available, and either have to expeditiously transfer patients for primary PCI, or use the strategy of fibrinolysis therapy with facilitated or rescue PCI. The current COVID-19 crisis has created an unprecedented paradigm shift with regard to the decision-making algorithm for STEMI patients especially in non-PCI-capable hospitals. Depending on regional transfer systems and potential delay in primary PCI, a strategy of thrombolysis first could be entertained at certain regional systems of care. The COVID-19 pandemic has caused a dramatic decline in the number of patient seeking care for myocardial infarction as well as a reduction in the accessibility of cardiac catheterization services. Regardless, professional societies continue to recommend PCI as the primary means of treatment for STEMI through the COVID-19 pandemic, and early multicenter data suggests the benefit of this therapy remains. Future research will be necessary and holds the key to proving this benefit persists beyond the immediate hospitalization time period both in the current era and in the context of possible future pandemics.
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Affiliation(s)
- Daniel Walters
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, La Jolla, CA 92037 USA
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, La Jolla, CA 92037 USA
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21
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Yu B, Akushevich I, Yashkin AP, Kravchenko J. Epidemiology of Geographic Disparities of Myocardial Infarction Among Older Adults in the United States: Analysis of 2000-2017 Medicare Data. Front Cardiovasc Med 2021; 8:707102. [PMID: 34568451 PMCID: PMC8458897 DOI: 10.3389/fcvm.2021.707102] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 07/29/2021] [Indexed: 01/29/2023] Open
Abstract
Background: There are substantial geographic disparities in the life expectancy (LE) across the U.S. with myocardial infarction (MI) contributing significantly to the differences between the states with highest (leading) and lowest (lagging) LE. This study aimed to systematically investigate the epidemiology of geographic disparities in MI among older adults. Methods: Data on MI outcomes among adults aged 65+ were derived from the Center for Disease Control and Prevention-sponsored Wide-Ranging Online Data for Epidemiologic Research database and a 5% sample of Medicare Beneficiaries for 2000–2017. Death certificate-based mortality from MI as underlying/multiple cause of death (CBM-UCD/CBM-MCD), incidence-based mortality (IBM), incidence, prevalence, prevalence at age 65, and 1-, 3-, and 5-year survival, and remaining LE at age 65 were estimated and compared between the leading and lagging states. Cox model was used to investigate the effect of residence in the lagging states on MI incidence and survival. Results: Between 2000 and 2017, MI mortality was higher in the lagging than in the leading states (per 100,000, CBM-UCD: 236.7–583.7 vs. 128.2–357.6, CBM-MCD: 322.7–707.7 vs. 182.4–437.7, IBM: 1330.5–1518.9 vs. 1003.3–1197.0). Compared to the leading states, lagging states had higher MI incidence (1.1–2.0% vs. 0.9–1.8%), prevalence (10.2–13.1% vs. 8.3–11.9%), pre-existing prevalence (2.5–5.1% vs. 1.4–3.6%), and lower survival (70.4 vs. 77.2% for 1-year, 63.2 vs. 67.2% for 3-year, and 52.1 vs. 58.7% for 5-year), and lower remaining LE at age 65 among MI patients (years, 8.8–10.9 vs. 9.9–12.8). Cox model results showed that the lagging states had greater risk of MI incidence [Adjusted hazards ratio, AHR (95% Confidence Interval, CI): 1.18 (1.16, 1.19)] and death after MI diagnosis [1.22 (1.21, 1.24)]. Study results also showed alarming declines in survival and remaining LE at age 65 among MI patients. Conclusion: There are substantial geographic disparities in MI outcomes, with lagging states having higher MI mortality, incidence, and prevalence, lower survival and remaining LE at age 65. Disparities in MI mortality in a great extent could be due to between-the-state differences in MI incidence, prevalence at age 65 and survival. Observed declines in survival and remaining LE require an urgent analysis of contributing factors that must be addressed.
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Affiliation(s)
- Bin Yu
- Department of Surgery, School of Medicine, Duke University, Durham, NC, United States.,Social Science Research Institute, Duke University, Durham, NC, United States.,Department of Preventive Medicine, School of Health Sciences, Wuhan University, Wuhan, China
| | - Igor Akushevich
- Social Science Research Institute, Duke University, Durham, NC, United States
| | - Arseniy P Yashkin
- Social Science Research Institute, Duke University, Durham, NC, United States
| | - Julia Kravchenko
- Department of Surgery, School of Medicine, Duke University, Durham, NC, United States
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22
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Dehghani P, Cantor WJ, Wang J, Wood DA, Storey RF, Mehran R, Bainey KR, Welsh RC, Rodés-Cabau J, Rao S, Lavi S, Velianou JL, Natarajan MK, Ziakas A, Guiducci V, Fernández-Avilés F, Cairns JA, Mehta SR. Complete Revascularization in Patients Undergoing a Pharmacoinvasive Strategy for ST-Segment-Elevation Myocardial Infarction: Insights From the COMPLETE Trial. Circ Cardiovasc Interv 2021; 14:e010458. [PMID: 34320839 DOI: 10.1161/circinterventions.120.010458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Payam Dehghani
- Prairie Vascular Research Network, University of Saskatchewan, Regina, Canada (P.D.)
| | - Warren J Cantor
- Toronto Southlake Regional Health Centre, University of Toronto, Ontario, Canada (W.J.C.)
| | - Jia Wang
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
- Population Health Research Institute, Hamilton, Ontario, Canada (J.W., M.K.N., S.R.M.)
| | - David A Wood
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Canada (D.A.W., J.A.C.)
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.)
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., R.C.W.)
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., R.C.W.)
| | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Canada (J.R.-C.)
| | - Sunil Rao
- Duke University Medical Center, Durham, NC (S.R.)
| | - Shahar Lavi
- London Health Sciences Centre, University of Western Ontario, Canada (S.L.)
| | - James L Velianou
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
| | - Madhu K Natarajan
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
- Population Health Research Institute, Hamilton, Ontario, Canada (J.W., M.K.N., S.R.M.)
| | - Antonios Ziakas
- AHEPA University Hospital, Aristotle University of Thessaloniki, Greece (A.Z.)
| | | | | | - John A Cairns
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Canada (D.A.W., J.A.C.)
| | - Shamir R Mehta
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
- Population Health Research Institute, Hamilton, Ontario, Canada (J.W., M.K.N., S.R.M.)
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Partow-Navid R, Prasitlumkum N, Mukherjee A, Varadarajan P, Pai RG. Management of ST Elevation Myocardial Infarction (STEMI) in Different Settings. Int J Angiol 2021; 30:67-75. [PMID: 34025097 DOI: 10.1055/s-0041-1723944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
ST-segment elevation myocardial infarction (STEMI) is a life-threatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe-reperfusion as quickly as possible-the management process is complicated and is affected by multiple factors including location, patient, and practitioner characteristics. Hence, this narrative review will discuss the recommended management and treatment strategies of STEMI in the circumstances.
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Affiliation(s)
- Rod Partow-Navid
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Narut Prasitlumkum
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ashish Mukherjee
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Padmini Varadarajan
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ramdas G Pai
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
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24
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Shen Y, Hsia RY. Differential benefits of cardiac care regionalization based on driving time to percutaneous coronary intervention. Acad Emerg Med 2021; 28:519-529. [PMID: 33319420 DOI: 10.1111/acem.14195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/25/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) require timely reperfusion, and percutaneous coronary intervention (PCI) decreases morbidity and mortality. Regionalization of STEMI care has increased timeliness and use of PCI, but it is unknown whether benefits to regionalization depend on a community's distance from its nearest PCI center. We sought to determine whether STEMI regionalization benefits, measured by access to PCI centers, timeliness of treatment (same-day or in-hospital PCI), and mortality, differ by baseline distance to nearest PCI center. METHODS Using a difference-in-difference-in-differences model, we examined access to PCI-capable hospitals, receipt of PCI either on the day of admission or during the care episode, and health outcomes for patients hospitalized from January 1, 2006, to September 30, 2015. RESULTS Of 139,408 patients (2006 to 2015), 51% could reach the nearest PCI center in <30 minutes, and 49% required ≥30 minutes driving time. For communities with baseline access ≥30 minutes, regionalization increased the probability of admission to a PCI-capable hospital by 9.4% and also increased the likelihood of receiving same-day PCI (by 11.2%) and PCI during the hospitalization (by 7.4%). Patients living within 30 minutes did not accrue significant benefits (measured by admission to a PCI-capable hospital or receipt of PCI) from regionalization initiatives. Regionalization more than halved access disparities and completely eliminated treatment disparities between communities ≥30 minutes and communities <30 minutes from the nearest PCI hospital. CONCLUSIONS Measured by likelihood of admission to a PCI-capable facility and receipt of PCI, benefits of STEMI regionalization in California accrued only to patients whose nearest PCI center was ≥30 minutes away. We found no mortality benefits of regionalization based on distance from PCI center. Our results suggest that policymakers focus STEMI regionalization efforts in communities that are not already well serviced by PCI-capable hospitals.
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Affiliation(s)
- Yu‐Chu Shen
- Graduate School of Defense Management Naval Postgraduate School Monterey California USA
- National Bureau of Economic Research Cambridge Massachusetts USA
| | - Renee Y. Hsia
- Department of Emergency Medicine University of California at San Francisco San Francisco California USA
- Philip R. Lee Institute for Health Policy StudiesUniversity of California at San Francisco San Francisco California USA
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25
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Shen YC, Krumholz H, Hsia RY. Association of Cardiac Care Regionalization With Access, Treatment, and Mortality Among Patients With ST-Segment Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2021; 14:e007195. [PMID: 33641339 DOI: 10.1161/circoutcomes.120.007195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Regionalization of ST-segment elevation myocardial infarction (STEMI) systems of care has been championed over the past decade. Although timely access to percutaneous coronary intervention (PCI) has been shown to improve outcomes, no studies have determined how regionalization has affected the care and outcomes of patients. We sought to determine if STEMI regionalization is associated with changes in access, treatment, and outcomes. METHODS Using a difference-in-differences approach, we analyzed a statewide, administrative database of 139 494 patients with STEMI in California from 2006 to 2015 using regionalization data based on a survey of all local Emergency Medical Services agencies in the state. RESULTS For patients with STEMI, the base rate of admission to a hospital with PCI capability was 72.7%, and regionalization was associated with an increase of 5.34 percentage points (95% CI, 1.58-9.10), representing a 7.1% increase. Regionalization was also associated with a statistically significant increase of 3.54 (95% CI, 0.61-6.48) percentage points in the probability of same-day PCI, representing an increase of 7.1% from the 49.7% base rate and a 4.6% relative increase (2.97 percentage points [95% CI, 0.1-5.85]) in the probability of receiving PCI at any time during the hospitalization. There was a 1.84 percentage point decrease (95% CI, -3.31 to -0.37) in the probability of receiving fibrinolytics. For 7-day mortality, regionalization was associated with a 0.53 (95% CI, -1 to -0.06) percentage point greater reduction (representing 5.8% off the base rate of 9.1%) and a 1.75 percentage point decrease in the likelihood of all-cause 30-day readmission (95% CI, -3.39 to -0.11; representing 6.4% off the base rate of 27.4%). No differences were found in longer-term mortality. CONCLUSIONS Among patients with STEMI in California from 2006 to 2015, STEMI regionalization was associated with increased access to a PCI-capable hospital, greater use of PCI, lower 7-day mortality, and lower 30-day readmissions.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Defense Management, Naval Postgraduate School (Y.-C.S.).,National Bureau of Economic Research (Y.-C.S.)
| | - Harlan Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine (H.K.).,Department of Health Policy and Management, Yale School of Public Health (H.K.).,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital (H.K.)
| | - Renee Y Hsia
- Department of Emergency Medicine (R.Y.H.), University of California at San Francisco.,Philip R. Lee Institute for Health Policy Studies (R.Y.H.), University of California at San Francisco
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26
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Aldstadt J, Waqas M, Yasumiishi M, Mokin M, Tutino VM, Rai HH, Chin F, Levy BR, Rai AT, Mocco J, Snyder KV, Davies JM, Levy EI, Siddiqui AH. Mapping access to endovascular stroke care in the USA and implications for transport models. J Neurointerv Surg 2021; 14:neurintsurg-2020-016942. [PMID: 33593798 DOI: 10.1136/neurintsurg-2020-016942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/12/2021] [Accepted: 01/19/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or state-designated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive. METHODS Stroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated. RESULTS Overall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive. CONCLUSION Nearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities.
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Affiliation(s)
- Jared Aldstadt
- National Center for Geographic Information and Analysis and Department of Geography, University at Buffalo - The State University of New York, Buffalo, New York, USA
| | - Muhammad Waqas
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Misa Yasumiishi
- National Center for Geographic Information and Analysis and Department of Geography, University at Buffalo - The State University of New York, Buffalo, New York, USA
| | - Maxim Mokin
- Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA.,Neurosciences Center, Tampa General Hospital, Tampa, Florida, USA
| | - Vincent M Tutino
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,University at Buffalo Canon Stroke and Vascular Research Center, Buffalo, New York, USA
| | - Hamid H Rai
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Felix Chin
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Bennett R Levy
- (Medical school student), The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - J Mocco
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kenneth V Snyder
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA.,Neurosurgery and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Jason M Davies
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA.,Neurosurgery and Bioinformatics and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Elad I Levy
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA .,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
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Yiadom MYAB, Olubowale OO, Jenkins CA, Miller KF, West JL, Vogus TJ, Lehmann CU, Antonello VD, Bernard GR, Storrow AB, Lindsell CJ, Liu D. Understanding timely STEMI treatment performance: A 3-year retrospective cohort study using diagnosis-to-balloon-time and care subintervals. J Am Coll Emerg Physicians Open 2021; 2:e12379. [PMID: 33644777 PMCID: PMC7890036 DOI: 10.1002/emp2.12379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE From the perspective of percutaneous coronary intervention (PCI) centers, locations of ST-segment elevation myocardial infarction (STEMI) diagnosis can include a referring facility, emergency medical services (EMS) transporting to a PCI center, or the PCI center's emergency department (ED). This challenges the use of door-to-balloon-time as the primary evaluative measure of STEMI treatment pathways. Our objective was to identify opportunities to improve care by quantifying differences in the timeliness of STEMI treatment mobilization based on the location of the diagnostic ECG. METHODS This 3-year, single-center, retrospective cohort study classified patients by diagnostic ECG location: referring facility, EMS, or PCI center ED. We quantified door-to-balloon-time and diagnosis-to-balloon-time with its care subintervals. RESULTS Of 207 ED STEMI patients, 180 (87%) received PCI. Median diagnosis-to-balloon-times were shortest among the ED-diagnosed (78 minutes [interquartile range (IQR), 61-92]), followed by EMS-identified patients (89 minutes [IQR, 78-122]), and longest among those referred (140 minutes [IQR, 119-160]), reflecting time for transport to the PCI center. Conversely, referred patients had the shortest median door-to-balloon-times (38 minutes [IQR, 34-43]), followed by the EMS-identified (64 minutes [IQR, 47-77]), whereas ED-diagnosed patients had the longest (89 minutes [IQR, 70-114]), reflecting diagnosis and catheterization lab activation frequently occurring before PCI center ED arrival for referred and EMS-identified patients. CONCLUSIONS Diagnosis-to-balloon-time and its care subintervals are complementary to the traditional door-to-balloon-times as measures of the STEMI treatment process. Together, they highlight opportunities to improve timely identification among ED-diagnosed patients, use of out-of-hospital cath lab activation for EMS-identified patients, and encourage pathways for referred patients to bypass PCI center EDs.
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Affiliation(s)
- Maame Yaa A. B. Yiadom
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Olayemi O. Olubowale
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Cathy A. Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Karen F. Miller
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jennifer L. West
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Timothy J. Vogus
- Owen Graduate School of ManagementVanderbilt UniversityNashvilleTennesseeUSA
| | - Christoph U. Lehmann
- Department of Biomedical Informatics & PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Victoria D. Antonello
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Gordon R. Bernard
- Department of Medicine, Division of Critical CareVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Alan B. Storrow
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Dandan Liu
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
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Hsia RY, Krumholz H, Shen YC. Evaluation of STEMI Regionalization on Access, Treatment, and Outcomes Among Adults Living in Nonminority and Minority Communities. JAMA Netw Open 2020; 3:e2025874. [PMID: 33196809 PMCID: PMC7670311 DOI: 10.1001/jamanetworkopen.2020.25874] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities. OBJECTIVE To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-in-difference-in-differences estimation approach. EXPOSURE Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization. MAIN OUTCOMES AND MEASURES Access to percutaneous coronary intervention (PCI)-capable hospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality. RESULTS This study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, -2.8 to -0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization. CONCLUSIONS AND RELEVANCE Although regionalization was associated with improved access to PCI hospitals and receipt of PCI treatment, patients in minority communities derived significantly smaller improvement relative to those in nonminority communities.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Harlan Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Yu-Chu Shen
- Graduate School of Defense Management, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
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29
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Dar MI, Beig JR, Jan I, Shah TR, Ali M, Rather HA, Tramboo NA. Prevalence of type 2 diabetes mellitus and association of HbA1c with severity of coronary artery disease in patients presenting as non-diabetic acute coronary syndrome. Egypt Heart J 2020; 72:66. [PMID: 32990846 PMCID: PMC7524918 DOI: 10.1186/s43044-020-00101-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/21/2020] [Indexed: 01/21/2023] Open
Abstract
Background Acute coronary syndrome (ACS) indicates the serious clinical manifestation of coronary artery disease (CAD) and is closely associated with cardiovascular prognosis in patients with ACS. This study was aimed to study the prevalence of type 2 diabetes mellitus (T2DM) and the relation of HbA1c with the severity of CAD in patients presenting as non-diabetic ACS. Diabetic status of the patients was assessed with fasting blood sugar (FBS) and HbA1c levels, and coronary artery disease burden was assessed by coronary angiography. Results Out of 208 patients, 85.1% were males, and 14.9% were females; 73.56% cases were hypertensive. 80.77% of cases had STEMI, 17.79% had NSTEMI, and 1.44% had unstable angina. Out of 168 STEMI patients, 64.3% were thrombolysed, 21.42% presented late, 2.38% had contraindications to thrombolysis, and 11.9% underwent primary PCI. FBS in diabetic range was found in 44.23% of cases, impaired FBS in 36.54%, and 19.23% of patients had FBS in non-diabetic range. According to HbA1c, 41.8% were diabetic, 39.4% were pre-diabetic, and 18.8% were non-diabetic. A significant positive correlation was found between HbA1c and Gensini score and between HbA1c and the number of vessels involved. Conclusion This study emphasises the importance of evaluating the presence of diabetes in patients presenting as non-diabetic acute coronary syndrome in developing countries. Acute coronary syndrome may be considered as one of the presentations of diabetes mellitus.
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Affiliation(s)
- Mohd Iqbal Dar
- Department of Cardiology, SKIMS Soura, Srinagar, Jammu and Kashmir, 190011, India.
| | - Jahangir Rashid Beig
- Department of Cardiology, SKIMS Soura, Srinagar, Jammu and Kashmir, 190011, India
| | - Iqra Jan
- Department of Immunology and Molecular Medicine, SKIMS Soura, Srinagar, Jammu and Kashmir, 190011, India
| | - Tariq Rashid Shah
- Department of Cardiology, SKIMS Soura, Srinagar, Jammu and Kashmir, 190011, India
| | - Muzaffar Ali
- Department of Cardiology, SKIMS Soura, Srinagar, Jammu and Kashmir, 190011, India
| | - Hilal A Rather
- Department of Cardiology, SKIMS Soura, Srinagar, Jammu and Kashmir, 190011, India
| | - Nisar A Tramboo
- Department of Cardiology, SKIMS Soura, Srinagar, Jammu and Kashmir, 190011, India
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Sarraj A, Pujara D, Grotta JC. Response by Sarraj et al to Letter Regarding Article, "Endovascular Thrombectomy for Acute Ischemic Strokes: Current US Access Paradigms and Optimization Methodology". Stroke 2020; 51:e175-e176. [PMID: 32646338 DOI: 10.1161/strokeaha.120.030852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Amrou Sarraj
- Department of Neurology, The University of Texas at Houston (A.S., D.P.)
| | - Deep Pujara
- Department of Neurology, The University of Texas at Houston (A.S., D.P.)
| | - James C Grotta
- Department of Neurology, Clinical Institute for Research and Innovation, Memorial Hermann Hospital - Texas Medical Center, Houston (J.C.G.)
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Fazel R, Joseph TI, Sankardas MA, Pinto DS, Yeh RW, Kumbhani DJ, Nallamothu BK. Comparison of Reperfusion Strategies for ST-Segment-Elevation Myocardial Infarction: A Multivariate Network Meta-analysis. J Am Heart Assoc 2020; 9:e015186. [PMID: 32500800 PMCID: PMC7429064 DOI: 10.1161/jaha.119.015186] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background We systematically reviewed trials comparing different reperfusion strategies for ST-segment-elevation myocardial infarction and used multivariate network meta-analysis to compare outcomes across these strategies. Methods and Results We identified 31 contemporary trials in which patients with ST-segment-elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as "facilitated PCI" when the median time interval between fibrinolysis to PCI was <2 hours (n=2259) and as a "pharmacoinvasive approach" when this interval was ≥2 hours (n=2747). We evaluated outcomes of death, nonfatal reinfarction, stroke, and major bleeding using a multivariate network meta-analysis and a Bayesian analysis. Among the strategies evaluated, primary PCI was associated with the lowest risk of mortality, nonfatal reinfarction, and stroke. For mortality, primary PCI had an odds ratio of 0.73 (95% CI, 0.61-0.89) when compared with fibrinolytic therapy. Of the remaining strategies, the pharmacoinvasive approach was the next most favorable with an odds ratio for death of 0.79 (95% CI, 0.59-1.08) compared with fibrinolytic therapy. The Bayesian model indicated that when the 2 strategies examining routine early invasive therapy following fibrinolysis were directly compared, the probability of adverse outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. Conclusions A pharmacoinvasive approach is safer and more effective than facilitated PCI and fibrinolytic therapy alone. This has significant implications for ST-segment-elevation myocardial infarction care in settings where timely access to primary PCI, the preferred treatment for ST-segment-elevation myocardial infarction, is not available.
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Affiliation(s)
- Reza Fazel
- Division of Cardiovascular Medicine Department of Medicine Beth Israel Deaconess Medical Center Boston MA
| | | | - Mullasari A Sankardas
- Department of Cardiology Institute of Cardiovascular Diseases The Madras Medical Mission Chennai India
| | - Duane S Pinto
- Department of Medicine Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA
| | - Robert W Yeh
- Department of Medicine Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA
| | - Dharam J Kumbhani
- Division of Cardiology Department of Medicine UT Southwestern Medical Center Dallas TX
| | - Brahmajee K Nallamothu
- Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence Ann Arbor Veterans Affairs Medical Center Ann Arbor MI.,Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Medical School Ann Arbor MI
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Shen YC, Chen G, Hsia RY. Community and Hospital Factors Associated With Stroke Center Certification in the United States, 2009 to 2017. JAMA Netw Open 2019; 2:e197855. [PMID: 31348507 PMCID: PMC6661722 DOI: 10.1001/jamanetworkopen.2019.7855] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The increased number of stroke centers in the United States may not be equitably distributed across all populations. Anecdotal reports suggest there may be differential proliferation in wealthier and urban communities. OBJECTIVE To examine hospital characteristics and economic conditions of communities surrounding hospitals with and without stroke centers. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all general, short-term, acute hospitals in the continental United States and used merged data from the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, state health departments, the Centers for Medicare & Medicaid Services, the American Hospital Association, the Dartmouth Atlas of Health Care, and the US Census Bureau from January 1, 2009, to September 30, 2017, to compare hospital and community characteristics of stroke-certified and non-stroke-certified hospitals and assessed characteristics of early and late adopters of stroke certification. MAIN OUTCOMES AND MEASURES Stroke center certification was the primary outcome. Risk factors were grouped into 3 categories: economic and financial, hospital, and community characteristics. Survival analyses were performed using a Cox proportional hazards regression model. RESULTS The study included 4546 US hospitals. During the study period, 1689 hospitals (37.2%) were stroke certified (961 adopted certification on or before January 1, 2009, 728 afterward). After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification (hazard ratio [HR], 0.62; 95% CI, 0.52-0.74 and HR, 0.87; 95% CI, 0.78-0.98, respectively). Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37). CONCLUSIONS AND RELEVANCE This study found that stroke centers have proliferated unevenly across geographic localities, where hospitals in high-income hospital service areas and with higher profit margins have a greater likelihood of being stroke certified. These findings suggest that market-driven factors may be associated with stroke center certification.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | | | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco
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Hsia RY, Huang D, Mann NC, Colwell C, Mercer MP, Dai M, Niedzwiecki MJ. A US National Study of the Association Between Income and Ambulance Response Time in Cardiac Arrest. JAMA Netw Open 2018; 1:e185202. [PMID: 30646394 PMCID: PMC6324393 DOI: 10.1001/jamanetworkopen.2018.5202] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
IMPORTANCE Emergency medical services (EMS) provide critical prehospital care, and disparities in response times to time-sensitive conditions, such as cardiac arrest, may contribute to disparities in patient outcomes. OBJECTIVES To investigate whether ambulance 9-1-1 times were longer in low-income vs high-income areas and to compare response times with national benchmarks of 4, 8, or 15 minutes across income quartiles. DESIGN, SETTING, AND PARTICIPANTS A retrospective cross-sectional study was performed of the 2014 National Emergency Medical Services Information System data in June 2017 using negative binomial and logistic regressions to examine the association between zip code-level income and EMS response times. The study used ambulance 9-1-1 response data for out-of-hospital cardiac arrest from 46 of 50 state repositories (92.0%) in the United States. The sample included 63 600 cardiac arrest encounters of patients who did not die on scene and were transported to the hospital. MAIN OUTCOMES AND MEASURES Four time measures were examined, including response time, on-scene time, transport time, and total EMS time. The study compared response times with EMS response time benchmarks for responding to cardiac arrest calls within 4, 8, and 15 minutes. RESULTS The study sample included 63 600 cardiac arrest encounters of patients (mean [SD] age, 60.6 [19.0] years; 57.9% male), with 37 550 patients (59.0%) from high-income areas and 8192 patients (12.9%) from low-income areas. High-income areas had greater proportions of white patients (70.1% vs 62.2%), male patients (58.8% vs 54.1%), privately insured patients (29.4% vs 15.9%), and uninsured patients (15.3% vs 7.9%), while low-income areas had a greater proportion of Medicaid-insured patients (38.3% vs 15.8%). The mean (SD) total EMS time was 37.5 (13.6) minutes in the highest zip code income quartile and 43.0 (18.8) minutes in the lowest. After controlling for urban zip code, weekday, and time of day in regression analyses, total EMS time remained 10% longer (95% CI, 9%-11%; P < .001), translating to 3.8 minutes longer in the poorest zip codes. The EMS response time to patients in high-income zip codes was more likely to meet 8-minute and 15-minute cutoffs compared with low-income zip codes. CONCLUSIONS AND RELEVANCE Patients with cardiac arrest from the poorest neighborhoods had longer EMS times compared with those from the wealthiest, and response times were less likely to meet national benchmarks in low-income areas, which may lead to increased disparities in prehospital delivery of care over time.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Delphine Huang
- Department of Emergency Medicine, University of California, San Francisco
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | | | - Mary P. Mercer
- Department of Emergency Medicine, University of California, San Francisco
| | - Mengtao Dai
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Matthew J. Niedzwiecki
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Mathematica Policy Research, Oakland, California
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Cesaro A, Gragnano F, Di Girolamo D, Moscarella E, Diana V, Pariggiano I, Alfieri A, Perrotta R, Golino P, Cesaro F, Mercone G, Campo G, Calabrò P. Functional assessment of coronary stenosis: an overview of available techniques. Is quantitative flow ratio a step to the future? Expert Rev Cardiovasc Ther 2018; 16:951-962. [DOI: 10.1080/14779072.2018.1540303] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Arturo Cesaro
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Felice Gragnano
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Domenico Di Girolamo
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Elisabetta Moscarella
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Vincenzo Diana
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Ivana Pariggiano
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Alfonso Alfieri
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Rocco Perrotta
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Pasquale Golino
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Francesco Cesaro
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Giuseppe Mercone
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Paolo Calabrò
- Division of Clinical Cardiology, A.O.R.N. Sant’Anna e San Sebastiano, Caserta, Italy
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy
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35
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Yang A, Pon Q, Lavoie A, Crawford JJ, Harenberg S, Zimmermann RH, Booker J, Kelly S, Lavi S, Cantor WJ, Mehta SR, Bagai A, Goodman SG, Cheema AN, Dehghani P. Long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in fibrinolytic-treated STEMI patients undergoing early PCI. J Thromb Thrombolysis 2018; 45:225-233. [PMID: 29170875 DOI: 10.1007/s11239-017-1581-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in patients undergoing early percutaneous coronary intervention (PCI) after fibrinolytic therapy is unknown. From May 2014 to August 2016, 212 patients undergoing PCI within 24 h of Tenecteplase (TNK), Aspirin, and Clopidogrel for ST-elevated myocardial infarction (STEMI) were randomized at four Canadian sites to receive additional Clopidogrel or Ticagrelor initiated prior to PCI. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline), at 4 and 24 h post PCI, and follow-up appointment. A mixed-model analysis with time as the repeated measure and drug as the between-subjects factor was calculated using 2 separate 1 × 4 ANOVAs, with students t-tests used to compare drugs within each time point. Complete clinical follow-up data (median 115.0 days; IQR 80.3-168.8) was available in 50 patients (23.6%) randomized to either Clopidogrel (n = 23) or Ticagrelor (n = 27). Analyses revealed significant decreases in PRU from baseline to 4 h (261.4 vs. 71.7; Mdiff = - 189.7; p < 0.001) to 24 h (71.7 vs. 27.7; Mdiff = - 44.0; p < 0.001) to end of follow-up (27.7 vs.17.9; Mdiff = - 9.9. p = 0.016) for those randomized to Ticagrelor and significant decreases in PRU only from baseline to 4 h (271.3 vs. 200.8; Mdiff = - 70.5, p = < 0.001) in patients receiving Clopidogrel, and a significantly greater proportion of patients with adequate platelet inhibition (PRU < 208) on long-term follow-up (Clopidogrel, 82.6% vs. Ticagrelor, 100.0%; p = 0.038). Our results demonstrate that in patients undergoing PCI within 24 h of fibrinolysis for STEMI, Ticagrelor provides prolonged platelet inhibition compared with Clopidogrel.
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Affiliation(s)
- Andrew Yang
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Quin Pon
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Andrea Lavoie
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Jennifer J Crawford
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Sebastian Harenberg
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Rodney H Zimmermann
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Jeff Booker
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Sheila Kelly
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Shahar Lavi
- London Health Sciences, University of London, London, ON, Canada
| | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Newmarket, ON, Canada
| | - Shamir R Mehta
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Asim N Cheema
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Payam Dehghani
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada.
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37
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Dehghani P, Lavoie A, Lavi S, Crawford JJ, Harenberg S, Zimmermann RH, Booker J, Kelly S, Cantor WJ, Mehta SR, Bagai A, Goodman SG, Cheema AN. Effects of ticagrelor versus clopidogrel on platelet function in fibrinolytic-treated STEMI patients undergoing early PCI. Am Heart J 2017; 192:105-112. [PMID: 28938956 DOI: 10.1016/j.ahj.2017.07.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/12/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Patients undergoing PCI early after fibrinolytic therapy are at high risk for both thrombotic and bleeding complications. We sought to assess the pharmacodynamic effects of ticagrelor versus clopidogrel in the fibrinolytic-treated STEMI patients undergoing early PCI. METHODS AND RESULTS Patients undergoing PCI within 24 hours of tenecteplase (TNK), aspirin, and clopidogrel for STEMI were randomized to receive additional clopidogrel 300 mg followed by 75 mg daily or ticagrelor 180 mg followed by 90 mg twice daily. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline) at 4 and 24 hours post-PCI. The primary end point was PRU ≤208 at 4 hours. A total of 140 patients (74 in ticagrelor and 66 in clopidogrel group) were enrolled. The mean PRU values at baseline were similar for the 2 groups (257.8±52.9 vs 259.5±56.7, P=.85, respectively). Post-PCI, patients on ticagrelor, compared to those on clopidogrel, had significantly lower PRU at 4 hours (78.7±88 vs 193.6±86.5, respectively, P<.001) and at 24 hours (34.5±35.0 and 153.5±75.5, respectively, P<.001). The primary end point was observed in 87.8% (n=65) in the ticagrelor-treated patients compared to 57.6% (n=38) of clopidogrel-treated patients, P<.001. CONCLUSION Fibrinolysis-treated STEMI patients who received clopidogrel and aspirin at the time of fibrinolysis and were undergoing early PCI frequently had PRU >208. In this high-risk population, ticagrelor provides more prompt and potent platelet inhibition compared with clopidogrel (Funded by Astra Zeneca; NCT01930591, https://clinicaltrials.gov/ct2/show/NCT01930591).
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Affiliation(s)
- Payam Dehghani
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada.
| | - Andrea Lavoie
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Shahar Lavi
- London Health Sciences, University of London, London, Ontario, Canada
| | - Jennifer J Crawford
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Sebastian Harenberg
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Rodney H Zimmermann
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Jeff Booker
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Sheila Kelly
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada
| | - Shamir R Mehta
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Asim N Cheema
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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38
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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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Tietschert MV, Angeli F, van Raak AJA, Ruwaard D, Singer SJ. Cross-Cultural Validation of the Patient Perception of Integrated Care Survey. Health Serv Res 2017; 53:1745-1776. [PMID: 28726236 DOI: 10.1111/1475-6773.12741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To test the cross-cultural validity of the U.S. Patient Perception of Integrated Care (PPIC) Survey in a Dutch sample using a standardized procedure. DATA SOURCES Primary data collected from patients of five primary care centers in the south of the Netherlands, through survey research from 2014 to 2015. STUDY DESIGN Cross-sectional data collected from patients who saw multiple health care providers during 6 months preceding data collection. DATA COLLECTION The PPIC survey includes 59 questions that measure patient perceived care integration across providers, settings, and time. Data analysis followed a standardized procedure guiding data preparation, psychometric analysis, and included invariance testing with the U.S. dataset. PRINCIPAL FINDINGS Latent scale structures of the Dutch and U.S. survey were highly comparable. Factor "Integration with specialist" had lower reliability scores and noninvariance. For the remaining factors, internal consistency and invariance estimates were strong. CONCLUSIONS The standardized cross-cultural validation procedure produced strong support for comparable psychometric characteristics of the Dutch and U.S. surveys. Future research should examine the usability of the proposed procedure for contexts with greater cultural differences.
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Affiliation(s)
- Maike V Tietschert
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Federica Angeli
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Arno J A van Raak
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Sara J Singer
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA
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Abshire DA, Lennie TA, Chung ML, Biddle MJ, Barbosa-Leiker C, Moser DK. Body Mass Index Category Moderates the Relationship Between Depressive Symptoms and Diet Quality in Overweight and Obese Rural-Dwelling Adults. J Rural Health 2017; 34:377-387. [PMID: 28686799 DOI: 10.1111/jrh.12255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/09/2017] [Accepted: 05/26/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE This study was conducted to (1) compare diet quality among depressed and nondepressed overweight and obese rural-dwelling adults and (2) determine whether body mass index (BMI) category moderates the relationship between depressive symptoms and overall diet quality. METHODS Rural adults in Kentucky (n = 907) completed the 9-item Patient Health Questionnaire (PHQ-9) that assessed depressive symptoms and a food frequency questionnaire that generated 2005 Healthy Eating Index (HEI) scores. Participants were grouped into overweight (BMI 25-29.9 kg/m2 ) and obese (≥30 kg/m2 ), and nondepressed (PHQ-9 < 10) and depressed (PHQ-9 ≥ 10) groups. Bootstrapped ANCOVAs were used to compare diet quality among the 4 groups. Ordinary least-squares regression using PROCESS was used to determine whether BMI category (overweight vs obese) moderated the association between depressive symptoms and overall diet quality. RESULTS Overall diet quality was poorer in the obese depressed group than in the obese nondepressed group. Intake of fruit and dark green/orange vegetables and legumes was lower in the obese depressed group than in the overweight nondepressed group. Depressive symptoms predicted poor overall diet quality (B = -0.287, P < .001) and the relationship was moderated by BMI category (coefficient of BMI category* depressive symptom interaction term = 0.355, P < .049). A significant inverse relationship between depressive symptoms and overall diet quality was observed in the overweight group but not in the obese group. CONCLUSION Components of diet quality vary according to BMI category and depressive symptom status. The relationship between depressive symptoms and diet quality is influenced by BMI category.
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Affiliation(s)
| | - Terry A Lennie
- College of Nursing, University of Kentucky, Lexington, Kentucky
| | - Misook L Chung
- College of Nursing, University of Kentucky, Lexington, Kentucky
| | - Martha J Biddle
- College of Nursing, University of Kentucky, Lexington, Kentucky
| | | | - Debra K Moser
- College of Nursing, University of Kentucky, Lexington, Kentucky
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