Comparative Effectiveness of Population Interventions to Improve Access to Reperfusion for ST-Segment–Elevation Myocardial Infarction in Australia

Long term survival after acute myocardial infarction in Australia and New Zealand, 2009-2015: a population cohort study

OBJECTIVE

To assess long term survival and patient characteristics associated with survival following acute myocardial infarction (AMI) in Australia and New Zealand.

DESIGN

Cohort study.

SETTING, PARTICIPANTS

All patients admitted with AMI (ICD-10-AM codes I21.0-I21.4) to all public and most private hospitals in Australia and New Zealand during 2009-2015.

MAIN OUTCOME MEASURE

All-cause mortality up to seven years after an AMI.

RESULTS

239 402 initial admissions with AMI were identified; the mean age of the patients was 69.3 years (SD, 14.3 years), 154 287 were men (64.5%), and 64 335 had ST-elevation myocardial infarction (STEMI; 26.9%). 7-year survival after AMI was 62.3% (STEMI, 70.8%; non-ST-elevation myocardial infarction [NSTEMI], 59.2%); survival exceeded 85% for people under 65 years of age, but was 17.4% for those aged 85 years or more. 120 155 patients (50.2%) underwent revascularisation (STEMI, 72.2%; NSTEMI, 42.1%); 7-year survival exceeded 80% for patients in each group who underwent revascularisation, and was lower than 45% for those who did not. Being older (85 years or older v 18-54 years: adjusted hazard ratio [aHR], 10.6; 95% CI, 10.1-11.1) or a woman (aHR, 1.15; 95% CI, 1.13-1.17) were each associated with greater long term mortality during the study period, as was prior heart failure (aHR, 1.79; 95% CI, 1.76-1.83). Several non-cardiac conditions and geriatric syndromes common in these patients were independently associated with lower long term survival, including major and metastatic cancer, cirrhosis and end-stage liver disease, and dementia.

CONCLUSION

AMI care in Australia and New Zealand is associated with high rates of long term survival; 7-year rates exceed 80% for patients under 65 years of age and for those who undergo revascularisation. Efforts to further improve survival should target patients with NSTEMI, who are often older and have several comorbid conditions, for whom revascularisation rates are low and survival after AMI poor.

Comparison of Real-Life Systems of Care for ST-Segment Elevation Myocardial Infarction

The success of ST-segment elevation myocardial infarction (STEMI) networks application in Europe and the United States in delivering rapid reperfusion therapy in the community have become an inspiration to other developing countries to develop regional STEMI network in order to improve the STEMI care. Although barriers are found in the beginning phase of constructing the network, recent analysis from national or regional registries worldwide have shown improvement of the STEMI care in many countries over the years. To improve the overall care of patients with STEMI particularly in developing countries, improvements should be focusing on how to minimize the total ischemia time, and this includes care improvement at each step of care after the patient shows signs and symptoms of chest pain. Innovation in health technology to develop the electrocardiogram transmission and communication system, along with routine performance measures of the STEMI network may help bridging the disparities of STEMI system of care between guideline recommended therapy and the real world clinical practice.

Sex Differences in Radial Access for Percutaneous Coronary Intervention in Acute Coronary Syndrome Are Independent of Body Size

BACKGROUND

Radial access reduces bleeding and is associated with improved survival following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). We evaluated the association between sex, markers of body size and radial access, and its impact on bleeding and mortality following PCI for ACS.

METHODS AND RESULTS

From 2013-2016, consecutive patients treated with PCI for ACS across 30 centres were prospectively entered into the Victorian Cardiac Outcomes Registry and followed for 30 days. Multivariate logistic regression was used to analyse predictors of the primary endpoint of PCI access site and secondary endpoints of major bleeding and mortality. A total of 16,330 ACS patients (40.9% ST elevation myocardial infarction [STEMI]) underwent PCI (23.5% female). Women were older with significantly lower weight and height compared to men. Women had lower radial access use (41.6% versus 51.0%, p<0.001), with higher 30-day major bleeding (2.4% versus 1.4%, p<0.001) and mortality (4.4% versus 3.4%, p<0.001) than men. Female sex independently predicted lower radial access use (OR 0.75, 95% CI 0.68-0.83, p<0.001) while body surface area, height and body mass index did not. Female sex was an independent predictor of higher 30-day major bleeding (OR 1.38, 95% CI 1.05-1.81, p=0.019) and mortality in STEMI patients (OR 1.31, 95% CI 1.01-1.70. p=0.039). Radial access was associated with lower major bleeding (OR 0.70, 95% CI 0.53-0.91, p=0.009) and mortality (OR 0.60, 95% CI 0.48-0.75, p<0.001).

CONCLUSIONS

Radial access, despite being associated with lower bleeding and mortality, was used less frequently in women, independent of co-morbidities and objective markers of body size.

Air vs. Road Decision for Endovascular Clot Retrieval in a Rural Telestroke Network

Background and Purpose: Telestroke aims to increase access to endovascular clot retrieval (ECR) for rural areas. There is limited information on transfer workflow for ECR in rural settings. We sought to describe the transfer metrics for ECR in a rural telestroke network with respect to decision making.

Methods: A retrospective cohort study was employed on consecutive patients transferred to the comprehensive stroke center (CSC) for ECR in a rural hub-and-spoke telestroke network between April 2013 and October 2019, by road or air. Key time-based metrics were analyzed.

Results: Sixty-two patients were included. Mean age was 66 years [standard deviation (SD), 14] and median National Institutes of Health Stroke Scale 13 [interquartile range (IQR), 8–18]. Median rural-hospital-door-to-CSC-door (D2D) was 308 min (IQR, 254–351), of which 68% was spent at rural hospitals [door-in-door-out (DIDO); 214 min; IQR, 171–247]. DIDO was longer for air transfers than road (P = 0.004), primarily because of a median 87 min greater decision-to-departure time (Decision-DO, P < 0.001). In multiple linear regression analysis, intubation but not thrombolysis was associated with significantly longer DIDO. The distance at which the extra speed of an aircraft made up for the delays involved in booking an aircraft was 299 km from the CSC.

Conclusions: DIDO is longer for air retrievals compared with road. Decision-DO represents the most important component of DIDO, being longer for air transfers. Systems for rapid transportation of rural ECR candidates need optimization for best patient outcomes, with decision support seen as a potential tool to achieve this.

Pre-hospital thrombolysis for ST-segment elevation myocardial infarction in regional Australia: long-term follow up

BACKGROUND

Delivering reperfusion therapy to patients with ST-segment elevation myocardial infarction (STEMI) in regional areas without access to tertiary cardiology care remains challenging. The systems of care in Hunter New England Health, New South Wales, Australia (area covered = 130 000 km² ) to provide reperfusion to patients with STEMI involve a 12-lead electrocardiogram in the ambulance, discussion between cardiologist and paramedic, followed by pre-hospital thrombolysis (PHT) delivered in ambulance to appropriate patients >60 min from the cardiac catheterisation laboratories. Patients who can access the cardiac catheterisation laboratories within 60 min are treated with primary percutaneous coronary intervention (PCI).

AIMS

We have previously reported excellent 12-month outcomes for patients receiving PHT and the aim of the current analysis is to look at the long term outcomes.

METHODS

We assessed long-term all-cause mortality and major adverse cardiovascular events of STEMI patients undergoing PHT in our health district from August 2008 to August 2013 and compared with the primary PCI group.

RESULTS

One hundred and fifty (mean age: 62 ± 13 years, males: 76%, n = 114) patients were administered PHT and 334 patients (mean age: 65 ± 13 years, males: 75%, n = 251) underwent primary PCI during the study period. During a median follow up of 6.2 years (interquartile range: 4.8-7.4 years) all-cause mortality was 16% and 19% in the PHT and primary PCI groups respectively (P = 0.4).

CONCLUSION

Our real-world experience shows that PHT followed by early transfer to a primary PCI-capable centre is an effective reperfusion strategy, with comparable results to primary PCI, and mortality benefits are sustained to more than 6 years.

Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks

BACKGROUND

The Mission: Lifeline STEMI Systems Accelerator program, implemented in 16 US metropolitan regions, resulted in more patients receiving timely reperfusion. We assessed whether implementing key care processes was associated with system performance improvement.

METHODS AND RESULTS

Hospitals (n=167 with 23 498 ST-segment-elevation myocardial infarction patients) were surveyed before (March 2012) and after (July 2014) program intervention. Data were merged with patient-level clinical data over the same period. For reperfusion, hospitals were grouped by whether a specific process of care was implemented, preexisting, or never implemented. Uptake of 4 key care processes increased after intervention: prehospital catheterization laboratory activation (62%-91%; P<0.001), single call transfer protocol from an outside facility (45%-70%; P<0.001), and emergency department bypass for emergency medical services direct presenters (48%-59%; P=0.002) and transfers (56%-79%; P=0.001). There were significant differences in median first medical contact-to-device times among groups implementing prehospital activation (88 minutes implementers versus 89 minutes preexisting versus 98 minutes nonimplementers; P<0.001 for comparisons). Similarly, patients treated at hospitals implementing single call transfer protocols had shorter median first medical contact-to-device times (112 versus 128 versus 152 minutes; P<0.001). Emergency department bypass was also associated with shorter median first medical contact-to-device times for emergency medical services direct presenters (84 versus 88 versus 94 minutes; P<0.001) and transfers (123 versus 127 versus 167 minutes; P<0.001).

CONCLUSIONS

The Accelerator program increased uptake of key care processes, which were associated with improved system performance. These findings support efforts to implement regional ST-segment-elevation myocardial infarction networks focused on prehospital catheterization laboratory activation, single call transfer protocols, and emergency department bypass.

Population access to reperfusion services for ST-segment elevation myocardial infarction in Kerala, India

Background

Population access to timely reperfusion is a decisive factor in determining the success and acceptability of any regional system of ST-segment elevation myocardial infarction (STEMI) care. We sought to determine the proportion of population of the southern Indian state of Kerala having timely access to STEMI reperfusion.

Methods

We identified the STEMI reperfusion facilities available at all acute-care hospitals, in Kerala, by conducting a cross-sectional survey. We mapped the geographical catchment areas of these hospitals using historical travel speeds and appropriate Geospatial Information Systems (GIS) analyses. Subsequently, using block level population data, we estimated the proportion of the population residing within these geographies.

Results

We estimated that 23.33 million people, forming 69.84% of the state population, resided in the green zone (within half-hour travel distance of a percutaneous coronary intervention [PCI]-capable hospital), which covered 47.94% of the geographical area of the state. Outside this green zone, 21.87% of the state population resided within 1 hr travel distance of a thrombolysis-capable hospital. Finally, 8.28% of the state population resided in the red zone, where access to any reperfusion-capable hospital took >1 hr, which covered 22.15% of the geographical area of the state.

Conclusions

A majority of the population of Kerala had timely access to PCI-capable hospitals. GIS-based mapping of Indian states, in terms of access to STEMI reperfusion, may help devise protocols to achieve seamless transfer of patients to reperfusion-capable hospitals. Such regionalization of STEMI care would enhance organizational synergies to achieve better access to reperfusion, especially in remote areas.

The distribution of maternity services across rural and remote Australia: does it reflect population need?

Background

Australia has a universal health care system and a comprehensive safety net. Despite this, outcomes for Australians living in rural and remote areas are worse than those living in cities. This study will examine the current state of equity of access to birthing services for women living in small communities in rural and remote Australia from a population perspective and investigates whether services are distributed according to need.

Methods

Health facilities in Australia were identified and a service catchment was determined around each using a one-hour road travel time from that facility. Catchment exclusions: metropolitan areas, populations above 25,000 or below 1,000, and a non-birthing facility within the catchment of one with birthing. Catchments were attributed with population-based characteristics representing need: population size, births, demographic factors, socio-economic status, and a proxy for isolation - the time to the nearest facility providing a caesarean section (C-section). Facilities were dichotomised by service level – those providing birthing services (birthing) or not (no birthing). Birthing services were then divided by C-section provision (C-section vs no C-section birthing). Analysis used two-stage univariable and multivariable logistic regression.

Results

There were 259 health facilities identified after exclusions. Comparing services with birthing to no birthing, a population is more likely to have a birthing service if they have more births, (adjusted Odds Ratio (aOR): 1.50 for every 10 births, 95% Confidence Interval (CI) [1.33-1.69]), and a service offering C-sections 1 to 2 h drive away (aOR: 28.7, 95% CI [5.59-148]). Comparing the birthing services categorised by C-section vs no C-section, the likelihood of a facility having a C-section was again positively associated with increasing catchment births and with travel time to another service offering C-sections. Both models demonstrated significant associations with jurisdiction but not socio-economic status.

Conclusions

Our investigation of current birthing services in rural and remote Australia identified disparities in their distribution. Population factors relating to vulnerability and isolation did not increase the likelihood of a local birthing facility, and very remote communities were less likely to have any service. In addition, services are influenced by jurisdictions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2084-8) contains supplementary material, which is available to authorized users.

Using a geographic information system to enhance patient access to point-of-care diagnostics in a limited-resource setting

BACKGROUND

Rapid and accurate diagnosis drives evidence-based care in health. Point-of-care testing (POCT) aids diagnosis by bringing advanced technologies closer to patients. Health small-world networks are constrained by natural connectivity in the interactions between geography of resources and social forces. Using a geographic information system (GIS) we can understand how populations utilize their health networks, visualize their inefficiencies, and compare alternatives.

METHODS

This project focuses on cardiac care resource in rural Isaan, Thailand. A health care access analysis was created using ArcGIS Network Analyst 10.1 from data representing aggregated population, roads, health resource facilities, and diagnostic technologies. The analysis quantified cardiac health care access and identified ways to improve it using both widespread and resource-limited strategies.

RESULTS

Results indicated that having diagnostic technologies closer to populations streamlines critical care paths. GIS allowed us to compare the effectiveness of the implementation strategies and put into perspective the benefits of adopting rapid POCT within health networks.

CONCLUSIONS

Geospatial analyses derive high impact by improving alternative diagnostic placement strategies in limited-resource settings and by revealing deficiencies in health care access pathways. Additionally, the GIS provides a platform for comparing relative costs, assessing benefits, and improving outcomes. This approach can be implemented effectively by health ministries seeking to enhance cardiac care despite limited resources.

Optimising acute care and secondary prevention for patients with acute coronary syndrome

Ascertaining a patient's risk of ischaemic complications after admission with an acute coronary syndrome is an important determinant of management. The treating clinician must determine whether and how urgently to send the patient for coronary angiography and whether to select more intensive antithrombotic therapies in the acute phase, and facilitate secondary prevention strategies. Risk stratification is infrequently applied and, as a consequence, undertreatment of higher-risk patients is common. Ensuring routine application of risk stratification across hospitals may improve treatment of patients who have the most to gain from evidence-based therapies. This requires embedding standard practices into complex clinical environments, and includes the routine implementation of treatment algorithms in a permissive environment with clinical champions and support from the hospital administration. The implementation of routine systems of care defining prehospital, interhospital and individual hospital practice is challenging, but essential to minimise deficits in care.

Shorter ischaemic time and improved survival with pre-hospital STEMI diagnosis and direct transfer for primary PCI

BACKGROUND

We sought to determine if our regional program for pre-hospital STEMI diagnosis and direct transfer for primary PCI (PPCI) was associated with shorter ischaemic times and improved survival compared with ED diagnosis.

METHODS

STEMI diagnosis was made at the scene by pre-hospital ECG or in local EDs depending on patient presentation. Ambulance ECGs were transmitted to our ED for cath lab activation. Patient variables and outcomes at 12 months were recorded.

RESULTS

We treated 782 consecutive patients with PPCI during January 2008-June 2013. Cath lab activation was initiated prior to hospital arrival (pre-hospital) in 24% of cases and by ED in 76% of cases. Median total ischaemic time was 154 min for pre-hospital and 211 minutes for ED patients (p<0.0001). Mortality at 12 months was 7.9% in the ED group compared with 3.7% in the pre-hospital group (p=0.036). On multivariate Cox regression analysis including baseline and procedural variables, pre-hospital activation remained an independent predictor of mortality (HR 0.45, 95% CI 0.20-1.0, p=0.03).

CONCLUSIONS

Pre-hospital diagnosis of STEMI and direct transfer to the cath lab reduced total ischaemic time by 57 minutes and mortality by >50% following PPCI. Further efforts are needed to increase the proportion of STEMI patients treated using this strategy.

Ten clinician-driven strategies for maximising value of Australian health care

OBJECTIVE

To articulate the concept of high-value care (i.e. clinically relevant, patient-important benefit at lowest possible cost) and suggest strategies by which clinicians can promote such care in rendering the Australian healthcare system more affordable and sustainable.

METHODS

Strategies were developed by the author based on personal experience in clinical practice, evidence-based medicine and quality improvement. Relevant literature was reviewed in retrieving studies supporting each strategy.

RESULTS

Ten strategies were developed: (1) minimise errors in diagnosis; (2) discontinue low- or no-value practices that provide little benefit or cause harm; (3) defer the use of unproven interventions; (4) select care options according to comparative cost-effectiveness; (5) target clinical interventions to those who derive greatest benefit; (6) adopt a more conservative approach nearing the end of life; (7) actively involve patients in shared decision making and self-management; (8) minimise day-to-day operational waste; (9) convert healthcare institutions into rapidly learning organisations; and (10) advocate for integrated patient care across all clinical settings.

CONCLUSIONS

Clinicians and their professional organisations, in partnership with managers, can implement strategies capable of maximising value and sustainability of health care in Australia. What is known about this topic? Value-based care has emerged as a unitary concept that integrates quality and cost, and is being increasingly used to inform healthcare policy making and reform. What does this paper add? There is scant literature that translates the concept of high value care into actionable enhancement strategies for clinicians in everyday practice settings. This article provides 10 strategies with supporting studies in an attempt to fill this gap. What are the implications for practitioners? If all practitioners, in partnership with healthcare managers, attempted to enact all 10 strategies in their workplaces, a significant quantum of healthcare resources could be redirected from low- to high-value care, culminating in much greater health benefit from the healthcare dollars currently being spent. However, such reforms will require a shift in clinician thinking and practice away from volume-based care to value-based care.

Impact of a regionalised clinical cardiac support network on mortality among rural patients with myocardial infarction

OBJECTIVE

To evaluate the impact of the regionalised Integrated Cardiovascular Clinical Network (ICCNet) on 30-day mortality among patients with myocardial infarction (MI) in an Australian rural setting.

DESIGN, SETTING AND PATIENTS

An integrated cardiac support network incorporating standardised risk stratification, point-of-care troponin testing and cardiologist-supported decision making was progressively implemented in non-metropolitan areas of South Australia from 2001 to 2008. Hospital administrative data and statewide death records from 1 July 2001 to 30 June 2010 were used to evaluate outcomes for patients diagnosed with MI in rural and metropolitan hospitals.

MAIN OUTCOME MEASURE

Risk-adjusted 30-day mortality.

RESULTS

29 623 independent contiguous episodes of MI were identified. The mean predicted 30-day mortality was lower among rural patients compared with metropolitan patients, while actual mortality rates were higher (30-day mortality: rural, 705/5630 [12.52%] v metropolitan, 2140/23 993 [8.92%]; adjusted odds ratio [OR], 1.46; 95% CI, 1.33-1.60; P< 0.001). After adjustment for temporal improvement in MI outcome, availability of immediate cardiac support was associated with a 22% relative odds reduction in 30-day mortality (OR, 0.78; 95% CI, 0.65-0.93; P= 0.007). A strong association between network support and transfer of patients to metropolitan hospitals was observed (before ICCNet, 1102/2419 [45.56%] v after ICCNet, 2100/3211 [65.4%]; P< 0.001), with lower mortality observed among transferred patients.

CONCLUSION

Cardiologist-supported remote risk stratification, management and facilitated access to tertiary hospital-based early invasive management are associated with an improvement in 30-day mortality for patients who initially present to rural hospitals and are diagnosed with MI. These interventions closed the gap in mortality between rural and metropolitan patients in South Australia.

Timely treatment for acute myocardial infarction and health outcomes: an integrative review of the literature

BACKGROUND

Coronary heart disease is the most common condition affecting Australians. The time sensitive nature of treating ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive research for several years. Despite important advances in strategies to reduce time to treatment, time continues to represent a major determinant of mortality and morbidity. Door to balloon time (DTBT) is a key indicator of quality of care for STEMI. Nurses play a pivotal role in streamlining the care processes to influence timely management of STEMI.

PURPOSE

The aim of this paper is to review the evidence on the time to treat STEMI, the associated factors impacting upon health outcomes and explore systems of care that reduce time to treatment, using an integrative review approach.

METHOD

Established databases were searched from 2000 to 2012. The search terms 'myocardial infarction', 'emergency medicine', 'angioplasty balloon', 'time factors', 'treatment outcome', 'mortality', 'prognosis', 'female', 'age factors', and 'readmission', were used in various combinations. Research studies that addressed the aims of this paper were examined.

FINDINGS

Twenty-nine papers were included in this integrative review. The literature demonstrates a strong relationship between shorter DTBT and reduced in-hospital mortality. Factors such as age, gender, time of presentation and co-morbid condition were associated with increased in-hospital mortality. There is sparse literature examining the effect timely reperfusion has on longer-term mortality and other longer-term outcomes such as readmission rates and occurrence of heart failure. Additionally, strategies that effectively reduced DTBT were identified, yet little has been reported on the impact reduced DTBT has had upon health outcomes and whether these improvements were sustained.

CONCLUSION

Whilst the importance of timely reperfusion is now well recognised, additional efforts to streamline the process of care and demonstrate sustained improvement for STEMI patients is required. Nurses in the areas of emergency medicine and cardiac care, play an essential role in facilitating this.

Contemporary themes in acute coronary syndrome management: from acute illness to secondary prevention

Acute coronary syndrome (ACS; myocardial infarction and unstable angina) is the leading cause of mortality in Australia, and those who survive one ACS event are at significant risk of experiencing another. Access to evidence-based and optimal ACS management in both the acute and long-term periods is of great importance. Management of ACS should include appropriate timely revascularisation, medical therapy and ongoing secondary prevention. A key consideration in selecting acute antithrombotic therapies is a careful determination of the risk of bleeding versus risk of recurrent ischaemia. Although there is a strong evidence base for the urgency of delivery and the quality of acute care, knowledge translation is suboptimal. There remains a need for ongoing research and policy development aimed at improving ease and equity of access to evidence-based care. Despite universal guideline recommendations for ongoing secondary prevention strategies, research indicates suboptimal use of evidence-based medications, poor adherence to lifestyle recommendations, and low levels of participation in traditional cardiac rehabilitation. Contemporary secondary prevention programs are evolving into flexible, multifaceted interventions to provide maximal clinical benefits to a majority of patients.

Reperfusion therapy for STEMI: is there still a role for thrombolysis in the era of primary percutaneous coronary intervention?

In the past ten years, primary percutaneous coronary intervention (PCI) has replaced thrombolysis as the revascularisation strategy for many patients presenting with ST-segment elevation myocardial infarction (STEMI). However, delivery of primary PCI within evidence-based timeframes is challenging, and health-care provision varies substantially worldwide. Consequently, even with the ideal circumstances of rapid initial diagnosis, long transfer delays to the catheter laboratory can occur. These delays are detrimental to outcomes for patients and can be exaggerated by variations in timing of patients' presentation and diagnosis. In this Series paper we summarise the value of immediate out-of-hospital thrombolysis for STEMI, and reconsider the potential therapeutic interface with a contemporary service for primary PCI. We review recent trial data, and explore opportunities for optimisation of STEMI outcomes with a pharmacoinvasive approach.

Evidence of systematic duplication by new percutaneous coronary intervention programs

BACKGROUND

Evidence suggests that recent and projected future investments in percutaneous coronary intervention (PCI) programs at US hospitals fail to increase access to timely reperfusion for patients with ST-segment elevation myocardial infarction.

METHODS AND RESULTS

We set out to estimate the annual number and costs of new PCI programs in US hospitals from 2004 to 2008 and identify the characteristics of hospitals, neighborhoods, and states where new PCI programs have been introduced. We estimated a discrete-time hazard model to measure the influence of these characteristics on the decision of a hospital to introduce a new PCI program. In 2008, 1739 US hospitals were capable of performing PCI, a relative increase of 16.5% (251 hospitals) over 2004. The percentage of the US population with projected access to timely PCI grew by 1.8%. New PCI programs were more likely to be introduced in areas that already had a PCI program with more competition for market share, near populations with higher rates of private insurance, in states that had weak or no regulation of new cardiac catheterization laboratories, and in wealthier and larger hospitals.

CONCLUSIONS

Our data show that new PCI programs were systematically duplicative of existing programs and did not help patients gain access to timely PCI. The total cost of recent US investments in new PCI programs is large and of questionable value for patients.