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Rutschman R, Alinier G, Scott G, Reimann T, Sliman Bounouh S, Castle NR, Olola C. Characterization of ST-Elevation Myocardial Infarction cases: Association between specific dispatcher-assigned dispatch determinant codes and hospital-confirmed STEMI cases in Qatar. PREHOSP EMERG CARE 2024:1-16. [PMID: 39172190 DOI: 10.1080/10903127.2024.2387721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVES ST-elevation myocardial infarction (STEMI) is an Acute Myocardial Infarction (AMI) with the greatest risk of death and disability. Getting diagnosed patients rapid definitive treatment at the correct facility is crucial in improving their outcome. Using a Question-and-Answer algorithm (Mobile Priority Dispatch System (MPDS®)), trained Emergency Medical Dispatchers (EMDs) can help identifying STEMI at the time of dispatch. This can assist Emergency Medical Services (EMS) pre-planning transport to potential STEMI-receiving hospitals. The study aimed to determine whether hospital-confirmed STEMI cases transported by ambulance are associated with certain dispatch determinant codes and identify the treatments performed. METHODS The retrospective study analyzed deidentified dispatch and hospital data of STEMI patients who were transported by Qatar's Ambulance Service between January 2018 and May 2021. Data analysis compared patient demographics with dispatch measures, considering chief complaint and determinant codes, and Percutaneous Coronary Intervention (PCI) treatment received. RESULTS A total of 3,724 STEMI cases with MPDS® dispatch codes were retrieved. After excluding patient transfer and pandemic-related cases, a final sample of 2,607 cases was analyzed. Most STEMI patients (86.0%) were classified as high priority levels at dispatch, had chest pain as chief complaint (62.9%), and were male (90.8%). Approximately, 99.0% of the STEMI patients received PCI treatment. Distributions of STEMI cases and PCI treatment did not significantly differ by patient demographics and dispatch measures. CONCLUSIONS Qatar's STEMI patients are more likely to be male and to receive adequate acute care irrespective of any demographic factor and despite potential language issues. This study highlights that the chief complaint may be described or interpreted differently when the questioning language is not their mother tongue, or when there is a language barrier between the caller, call taker, or when using the MPDS® protocols language or when self-translating questions instantly in another language. Therefore, EMDs should be made aware of the language differences and be encouraged to further clarify the chief complaint when appropriate. There may be a need for potential refinements of the MPDS® questioning algorithm and EMD training with AMI symptoms reinforcement. This could help improve their early identification of STEMI cases with non-classic chest pain symptoms.
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Affiliation(s)
- Ross Rutschman
- Priority Dispatch Corp., Inc., Salt Lake City, Utah, USA
| | - Guillaume Alinier
- Hamad Medical Corporation Ambulance Service, Doha, Qatar
- School of Health and Social Work, University for Hertfordshire, Hatfield, UK
- Weill Cornell Medicine-Qatar, Doha, Qatar
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Greg Scott
- Priority Dispatch Corp., Inc., Salt Lake City, Utah, USA
| | - Thomas Reimann
- Hamad Medical Corporation Ambulance Service, Doha, Qatar
| | | | | | - Christopher Olola
- International Academies of Emergency Dispatch, Salt Lake City, Utah, USA
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Hsia RY, Redberg RF, Shen YC. Is more better? A multilevel analysis of percutaneous coronary intervention hospital openings and closures on patient volumes. Acad Emerg Med 2024. [PMID: 38752293 DOI: 10.1111/acem.14926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/12/2024] [Accepted: 04/04/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND It is unknown how changes in the percutaneous coronary intervention (PCI) "built environment" have impacted PCI volumes at the community, hospital, and patient levels. This study sought to determine how PCI hospital openings and closures effect community- and hospital-level PCI volumes as well as the likelihood of receiving PCI at a low-volume hospital. METHODS We conducted a retrospective cohort study of 3,966,025 Medicare Fee-For-Service patients in 37,451 zip codes and 2564 U.S. hospitals who underwent PCI from 2006 to 2017. We conducted community-, hospital-, and patient-level analyses using ordinary least squares regressions with fixed effects to determine changes in PCI volumes after PCI hospital openings or closures. RESULTS Between 2006 and 2017, a total of 17% and 7% of patients lived in communities that experienced PCI hospital openings and closures, respectively. Openings were associated with a 10% increase in community PCI volume, a 2% increase in the share of elective PCI, and a doubling in the likelihood of receiving PCI at a low-volume hospital. In communities with low baseline PCI capacity, openings were associated with a 12% increase in community PCI volume, and in high-capacity communities, an 8% increase. PCI closures were associated with a 9% decrease in community PCI volume in high-capacity communities but no measurable change in low-capacity communities. CONCLUSIONS PCI service expansion is associated with increased PCI at low-volume hospitals and a greater number of elective procedures. Increased governmental oversight may be necessary to ensure that openings and closures of these specialized services yield the desired benefits.
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Affiliation(s)
- Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Rita F Redberg
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
- Division of Cardiology, Department of Medicine, University of California, San Francisco, California, USA
| | - Yu-Chu Shen
- Department of Defense Management, Naval Postgraduate School, Monterey, California, USA
- National Bureau of Economic Research, Cambridge, Massachusetts, USA
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Ward MJ, Nikpay S, Shermeyer A, Nallamothu BK, Rokos I, Self WH, Hsia RY. Interfacility Transfer of Uninsured vs Insured Patients With ST-Segment Elevation Myocardial Infarction in California. JAMA Netw Open 2023; 6:e2317831. [PMID: 37294567 PMCID: PMC10257096 DOI: 10.1001/jamanetworkopen.2023.17831] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/26/2023] [Indexed: 06/10/2023] Open
Abstract
Importance Insurance status has been associated with whether patients with ST-segment elevation myocardial infarction (STEMI) presenting to emergency departments are transferred to other facilities, but whether the facility's percutaneous coronary intervention capabilities mediate this association is unknown. Objective To examine whether uninsured patients with STEMI were more likely than patients with insurance to experience interfacility transfer. Design, Setting, and Participants This observational cohort study compared patients with STEMI with and without insurance who presented to California emergency departments between January 1, 2010, and December 31, 2019, using the Patient Discharge Database and Emergency Department Discharge Database from the California Department of Health Care Access and Information. Statistical analyses were completed in April 2023. Exposures Primary exposures were lack of insurance and facility percutaneous coronary intervention capabilities. Main Outcomes and Measures The primary outcome was transfer status from the presenting emergency department of a percutaneous coronary intervention-capable hospital, defined as a facility performing 36 percutaneous coronary interventions per year. Multivariable logistic regression models with multiple robustness checks were performed to determine the association of insurance status with the odds of transfer. Results This study included 135 358 patients with STEMI, of whom 32 841 patients (24.2%) were transferred (mean [SD] age, 64 [14] years; 10 100 women [30.8%]; 2542 Asian individuals [7.7%]; 2053 Black individuals [6.3%]; 8285 Hispanic individuals [25.2%]; 18 650 White individuals [56.8%]). After adjusting for time trends, patient factors, and transferring hospital characteristics (including percutaneous coronary intervention capabilities), patients who were uninsured had lower odds of experiencing interfacility transfer than those with insurance (adjusted odds ratio, 0.93; 95% CI, 0.88-0.98; P = .01). Conclusions and Relevance After accounting for a facility's percutaneous coronary intervention capabilities, lack of insurance was associated with lower odds of emergency department transfer for patients with STEMI. These findings warrant further investigation to understand the characteristics of facilities and outcomes for uninsured patients with STEMI.
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Affiliation(s)
- Michael J. Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Sayeh Nikpay
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Andrew Shermeyer
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Brahmajee K. Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
- Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Ivan Rokos
- Department of Emergency Medicine, UCLA-Olive View, Los Angeles, California
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco
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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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Gottula AL, Shaw CR, Gorder KL, Lane BH, Latessa J, Qi M, Koshoffer A, Al-Araji R, Young W, Bonomo J, Langabeer JR, Yannopoulos D, Henry TD, Hsu CH, Benoit JL. Eligibility of out-of-hospital cardiac arrest patients for extracorporeal cardiopulmonary resuscitation in the United States: A geographic information system model. Resuscitation 2022; 180:111-120. [PMID: 36183812 DOI: 10.1016/j.resuscitation.2022.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent evidence suggest that extracorporeal cardiopulmonary resuscitation (ECPR) may improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). Eligibility criteria for ECPR are often based on patient age, clinical variables, and facility capabilities. Expanding access to ECPR across the U.S. requires a better understanding of how these factors interact with transport time to ECPR centers. METHODS We constructed a Geographic Information System (GIS) model to estimate the number of ECPR candidates in the U.S. We utilized a Resuscitation Outcome Consortium (ROC) database to model time-dependent rates of ECPR eligibility and the Cardiac Arrest Registry to Enhance Survival (CARES) registry to determine the total number of OHCA patients who meet pre-specified ECPR criteria within designated transportation times. The combined model was used to estimate the total number of ECPR candidates. RESULTS There were 588,203 OHCA patients in the CARES registry from 2013 to 2020. After applying clinical eligibility criteria, 22,104 (3.76%) OHCA patients were deemed eligible for ECPR. The rate of ROSC increased with longer resuscitation time, which resulted in fewer ECPR candidates. The proportion of OHCA patients eligible for ECPR increased with older age cutoffs. Only 1.68% (9,889/588,203) of OHCA patients in the U.S. were eligible for ECPR based on a 45-minute transportation time to an ECMO-ready center model. CONCLUSIONS Less than 2% of OHCA patients are eligible for ECPR in the U.S. GIS models can identify the impact of clinical criteria, transportation time, and hospital capabilities on ECPR eligibility to inform future implementation strategies.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Michigan, United States; Department of Anesthesiology, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States.
| | - Christopher R Shaw
- Department of Medicine Division of Pulmonary and Critical Care, Oregon Health and Science University, United States
| | - Kari L Gorder
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Bennett H Lane
- Department of Emergency Medicine, University of Cincinnati, United States.
| | - Jennifer Latessa
- Department of Planning, The University of Cincinnati, United States.
| | - Man Qi
- Department of Geography and Geographic Information System, The University of Cincinnati, United States.
| | - Amy Koshoffer
- University of Cincinnati Libraries, The University of Cincinnati, United States.
| | - Rabab Al-Araji
- Department of Emergency Medicine, Emory University, United States; The Cardiac Arrest Registry to Enhance Survival, United States.
| | - Wesley Young
- College of Medicine, The University of Cincinnati, United States
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, United States; Department of Neurosurgery, University of Cincinnati, United States.
| | - James R Langabeer
- Department of Emergency, Medicine McGovern School of Medicine, The University of Texas Health Center, United States; UT School of Public Health, The University of Texas Health Center, United States; School of Biomedical Informatics, The University of Texas Health Center, United States.
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, United States.
| | - Cindy H Hsu
- Department of Emergency Medicine, University of Michigan, United States; Max Harry Weil Institute for Critical Care Research and Innovation, United States; Department of Surgery, University of Michigan, United States.
| | - Justin L Benoit
- Department of Emergency Medicine, University of Cincinnati, United States.
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Hillerson D, Li S, Misumida N, Wegermann ZK, Abdel-Latif A, Ogunbayo GO, Wang TY, Ziada KM. Characteristics, Process Metrics, and Outcomes Among Patients With ST-Elevation Myocardial Infarction in Rural vs Urban Areas in the US: A Report From the US National Cardiovascular Data Registry. JAMA Cardiol 2022; 7:1016-1024. [PMID: 36044196 PMCID: PMC9434481 DOI: 10.1001/jamacardio.2022.2774] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/06/2022] [Indexed: 11/14/2022]
Abstract
Importance Patients with ST-segment elevation myocardial infarction (STEMI) living in rural settings often have worse clinical outcomes compared with their urban counterparts. Whether this discrepancy is due to clinical characteristics or delays in timely reperfusion with primary percutaneous coronary intervention (PPCI) or fibrinolysis is unclear. Objective To assess process metrics and outcomes among patients with STEMI in rural and urban settings across the US. Design, Setting, and Participants This cross-sectional multicenter study analyzed data for 70 424 adult patients with STEMI from the National Cardiovascular Data Registry Chest Pain-MI Registry in 686 participating US hospitals between January 1, 2019, and June 30, 2020. Patients without a valid zip code were excluded, and those transferred to a different hospital during the course of the study were excluded from outcome analysis. Main Outcomes and Measures In-hospital mortality and time-to-reperfusion metrics. Results This study included 70 424 patients with STEMI (median [IQR] age, 63 [54-73] years; 49 850 [70.8%] male and 20 574 [29.2%] female; patient self-reported race: 6753 [9.6%] Black, 60 114 [85.4%] White, and 2096 [3.0%] of another race [including American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander]; 5281 [7.5%] individuals of Hispanic or Latino ethnicity) in 686 hospitals (50 702 [72.0%] living in urban zip codes and 19 722 [28.0%] in rural zip codes). Patients from rural settings were less likely to undergo PPCI compared with patients from urban settings (14 443 [73.2%] vs 43 142 [85.1%], respectively; P < .001) and more often received fibrinolytics (2848 [19.7%] vs 937 [2.7%]; P < .001). Compared with patients from urban settings, those in rural settings undergoing PPCI had longer median (IQR) time from first medical contact to catheterization laboratory activation (30 [12-42] minutes vs 22 [15-59] minutes; P < .001) and longer median (IQR) time from first medical contact to device (99 minutes [75-131] vs 81 [66-103] minutes; P < .001), including those who arrived directly at PPCI centers (83 [66-107] minutes vs 78 [64-97] minutes; P < .001) and those who transferred to PPCI centers from another treatment center (125 [102-163] minutes vs 103 [85-135] minutes; P < .001). Among those who transferred in, median (IQR) door-in-door-out time was longer in patients from rural settings (63 [41-100] minutes vs 50 [35-80] minutes; P < .001). Out-of-hospital cardiac arrest was more common in patients from urban vs rural settings (3099 [6.1%] vs 958 [4.9%]; P < .001), and patients from urban settings were more likely to present with heart failure (4112 [8.1%] vs 1314 [6.7%]; P < .001). After multivariable adjustment, there was no significant difference in in-hospital mortality between rural and urban groups (adjusted odds ratio, 0.97; 95% CI, 0.89-1.06). Conclusions and Relevance In this large cohort of patients with STEMI from US hospitals participating in the National Cardiovascular Data Registry Chest Pain-MI Registry, patients living in rural settings had longer times to reperfusion, were less likely to receive PPCI or meet guideline-recommended time to reperfusion, and more frequently received fibrinolytics than patients living in urban settings. However, there was no difference in adjusted in-hospital mortality between patients with STEMI from urban and rural settings.
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Affiliation(s)
- Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Shuang Li
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Naoki Misumida
- Gill Heart and Vascular Institute, University of Kentucky, Lexington
| | - Zachary K. Wegermann
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Ahmed Abdel-Latif
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
- Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
| | | | - Tracy Y. Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Khaled M. Ziada
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Kataruka A, Maynard CC, Hira RS, Dean L, Dardas T, Gurm H, Brown J, Ring ME, Doll JA. Government Regulation and Percutaneous Coronary Intervention Volume, Access and Outcomes: Insights From the Washington State Cardiac Care Outcomes Assessment Program. J Am Heart Assoc 2022; 11:e025607. [PMID: 36056726 PMCID: PMC9496421 DOI: 10.1161/jaha.122.025607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background It is unclear how to geographically distribute percutaneous coronary intervention (PCI) programs to optimize patient outcomes. The Washington State Certificate of Need program seeks to balance hospital volume and patient access through regulation of elective PCI. Methods and Results We performed a retrospective cohort study of all non‐Veterans Affairs hospitals with PCI programs in Washington State from 2009 to 2018. Hospitals were classified as having (1) full PCI services and surgical backup (legacy hospitals, n=17); (2) full services without surgical backup (new certificate of need [CON] hospitals, n=9); or (3) only nonelective PCI without surgical backup (myocardial infarction [MI] access hospitals, n=9). Annual median hospital‐level volumes were highest at legacy hospitals (605, interquartile range, 466–780), followed by new CON, (243, interquartile range, 146–287) and MI access, (61, interquartile range, 23–145). Compared with MI access hospitals, risk‐adjusted mortality for nonelective patients was lower for legacy (odds ratio [OR], 0.59 [95% CI, 0.48–0.72]) and new‐CON hospitals (OR, 0.55 [95% CI, 0.45–0.65]). Legacy hospitals provided access within 60 minutes for 90% of the population; addition of new CON and MI access hospitals resulted in only an additional 1.5% of the population having access within 60 minutes. Conclusions Many PCI programs in Washington State do not meet minimum volume standards despite regulation designed to consolidate elective PCI procedures. This CON strategy has resulted in a tiered system that includes low‐volume centers treating high‐risk patients with poor outcomes, without significant increase in geographic access. CON policies should re‐evaluate the number and distribution of PCI programs.
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Affiliation(s)
- Akash Kataruka
- Division of Cardiology University of Washington Seattle WA
| | | | | | - Larry Dean
- Division of Cardiology University of Washington Seattle WA
| | - Todd Dardas
- Division of Cardiology University of Washington Seattle WA
| | - Hitinder Gurm
- Division of Cardiology University of Michigan Ann Arbor MI
| | - Josiah Brown
- Division of Cardiology Cedars Sinai Los Angeles CA
| | | | - Jacob A Doll
- Division of Cardiology University of Washington Seattle WA.,VA Puget Sound Health Care System Seattle WA
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Mørk SR, Bøtker MT, Hjort J, Jensen LO, Pedersen F, Jørgensen G, Christensen EF, Christensen MK, Aarø J, Lippert F, Knudsen L, Hansen TM, Steinmetz J, Terkelsen CJ. Use of Helicopters to Reduce Health Care System Delay in Patients With ST-Elevation Myocardial Infarction Admitted to an Invasive Center. Am J Cardiol 2022; 171:7-14. [PMID: 35282876 DOI: 10.1016/j.amjcard.2022.01.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 12/12/2022]
Abstract
Timely reperfusion in ST-elevation myocardial infarction (STEMI) is essential. This study aimed to evaluate the reduction in system delay (time from emergency medical service [EMS] call to primary percutaneous coronary intervention [PPCI]) in patients with STEMI when using helicopter EMS (HEMS) rather than ground-based EMS (GEMS). This was a retrospective, nationwide cohort study of consecutive patients with STEMI treated with PPCI at 5 PPCI centers in Denmark. Polynomial spline curves were constructed to describe the association between system delay and distance to the PPCI center stratified by transportation mode. A total of 26,433 patients with STEMI were treated with PPCI between January 1, 1999, and December 31, 2016. In 16,436 patients field triaged directly to the PPCI center, the proportion treated within 120 minutes of the EMS call was 75% for those living 0 to 25 km from the PPCI center compared with 65% for all patients transported by GEMS (median transport distance 50 km [interquartile range 23 to 90]) and 64% for all patients transported by HEMS (median transport distance 119 km [interquartile range 99 to 142]). The estimated reduction in system delay owed to using HEMS rather than GEMS was 14, 16, 20, and 29 minutes for patients living 75, 100, 125, and 170 km from a PPCI center. In conclusion, this study confirmed that using HEMS ensures that most patients with STEMI, living up to 170 km from a PPCI center, can be treated within 120 minutes of their EMS call provided they are field triaged directly to the PPCI center.
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Affiliation(s)
| | | | - Jakob Hjort
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Frants Pedersen
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gitte Jørgensen
- Prehospital Medical Services, Region of Southern Denmark, Denmark
| | - Erika Frischknect Christensen
- Prehospital Medical Services, North Denmark Region, Denmark; Department of Emergency and Trauma Care, Centre for Internal Medicine and Emergency Care; Centre for Prehospital and Emergency Research, Aalborg University Hospital and Institute for Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Jens Aarø
- Department of Cardiology, Aalborg University Hospital, Denmark
| | - Freddy Lippert
- Prehospital Medical Services, Capital Region of Denmark, Denmark
| | | | | | | | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; The Danish Heart Foundation, Denmark
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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: 4] [Impact Index Per Article: 2.0] [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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10
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Dharma S, Kamarullah W, Sabrina AP. Association of Admission Time and Mortality in STEMI Patients: A Systematic Review and Meta-analysis. Int J Angiol 2022; 31:273-283. [PMID: 36588865 PMCID: PMC9803553 DOI: 10.1055/s-0042-1742610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
This systematic review and meta-analysis aimed to evaluate patients with acute ST-segment elevation myocardial infarction (STEMI) who were admitted during off-hours and treated with primary angioplasty associated with an increased risk of mortality compared with those admitted during regular working hours. We performed a systematic literature search using PubMed, SCOPUS, Europe PMC, and Cochrane CENTRAL databases that was finalized on March 15, 2021. The primary outcome was mortality comprising early (in-hospital), midterm (30 days to 1 year), and long-term mortality (>1 year). A total of 384,452 patients from 56 studies were included. The overall mortality of acute STEMI patients admitted during off-hours and regular hours were 6.1 and 6.7%, respectively. Patients admitted during off-hours had similar risk of early, midterm, and long-term mortality compared to those admitted during regular working hours ([relative risk or RR = 1.07, 95% confidence interval or CI, 1.00-1.14, p = 0.06; I 2 = 45%, p = 0.0009], [RR = 1.00, 95% CI, 0.95-1.05, p = 0.92; I 2 = 13%, p = 0.26], and [RR = 0.95, 95% CI, 0.86-1.04, p = 0.26; I 2 = 0%, p = 0.76], respectively). Subgroup analyses indicated that the results were consistent across all subgroups ([women vs. men], [age >65 years vs. ≤65 years], and [Killip classification II to IV vs. Killip I]). Funnel plot was asymmetrical. However, Egger's test suggests no significance of small-study effects ( p = 0.19). This meta-analysis showed that patients with acute STEMI who were admitted during off-hours and treated with primary angioplasty had similar risk of early, midterm, and long-term mortality compared with those admitted during regular working hours.
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Affiliation(s)
- Surya Dharma
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia,Faculty of Medicine, University of Prima Indonesia, Medan, Indonesia,Address for correspondence Surya Dharma, MD, PhD Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan KitaJl. S Parman Kav 87, Slipi, Jakarta Barat, 11420, JakartaIndonesia
| | - William Kamarullah
- Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Adelia Putri Sabrina
- Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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11
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Handran CB, Kunz M, Larson DM, Garberich RF, Baran K, Henry JT, Sharkey SW, Henry TD. The impact of regional STEMI systems on protocol use and quality improvement initiatives in community hospitals without cardiac catheterization laboratories. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100077. [PMID: 38560053 PMCID: PMC10978212 DOI: 10.1016/j.ahjo.2021.100077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 04/04/2024]
Abstract
Study objective Since the 1990s, national guidelines have recommended hospitals develop STEMI treatment protocols and monitor quality. A 2003 survey of Minnesota hospitals without cardiac catheterization laboratories (CCL) found <2/3 had STEMI protocols, <50% had a quality assessment (QA) process, and protocols in existence were incomplete. We evaluated temporal changes in STEMI processes in relationship to changes in mortality. Design setting and participants Follow-up surveys were mailed to emergency departments at 108 Minnesota hospitals without CCL. Results Among 87% of responding hospitals, 89% had formal protocols or guidelines for STEMI management compared to 63% in 2003 (p < 0.001). In 2010, 67% of hospitals had triage/transfer criteria and 15% of hospitals used protocols for transfer decisions, compared to only 8% (p < 0.001) and 1% (p = 0.098), respectively, in 2003. The percentage of hospitals transferring patients with STEMI from the emergency department increased from 23% in 2003 to 56% in 2010 (p < 0.001). During this time, age-adjusted acute MI mortality rate in Minnesota decreased 33% and was more pronounced in areas with regional STEMI systems. Conclusions Since 2003, utilization of STEMI guidelines, protocols, and standing orders in Minnesota hospitals without CCL has markedly improved with <10% of hospitals lacking specific STEMI management protocols. The majority of hospitals routinely transfer patients with STEMI for primary PCI and have comprehensive QA processes. This improvement was stimulated by regional STEMI systems, further supporting the current class I recommendation for STEMI systems of care in current guidelines. The decline in Minnesota STEMI mortality paralleled the growth of regional STEMI systems.
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Affiliation(s)
| | - Miranda Kunz
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - David M. Larson
- Ridgeview Medical Center, Waconia, MN, United States of America
| | - Ross F. Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Kelsey Baran
- Berkshire Medical Center, Pittsfield, MA, United States of America
| | - Jason T. Henry
- Sarah Cannon Research Institute at HealthONE, Denver, CO, United States of America
| | - Scott W. Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH, United States of America
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12
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Doll JA, O'Donnell CI, Plomondon ME, Waldo SW. Contemporary Clinical and Coronary Anatomic Risk Model for 30-Day Mortality After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2021; 14:e010863. [PMID: 34903032 DOI: 10.1161/circinterventions.121.010863] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) procedures are increasing in clinical and anatomic complexity, likely increasing the calculated risk of mortality. There is need for a real-time risk prediction tool that includes clinical and coronary anatomic information that is integrated into the electronic medical record system. METHODS We assessed 70 503 PCIs performed in 73 Veterans Affairs hospitals from 2008 to 2019. We used regression and machine-learning strategies to develop a prediction model for 30-day mortality following PCI. We assessed model performance with and without inclusion of the Veterans Affairs SYNTAX score (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), an assessment of anatomic complexity. Finally, the discriminatory ability of the Veterans Affairs model was compared with the CathPCI mortality model. RESULTS The overall 30-day morality rate was 1.7%. The final model included 14 variables. Presentation status (salvage, emergent, urgent), ST-segment-elevation myocardial infarction, cardiogenic shock, age, congestive heart failure, prior valve disease, chronic kidney disease, chronic lung disease, atrial fibrillation, elevated international normalized ratio, and the Veterans Affairs SYNTAX score were all associated with increased risk of death, while increasing body mass index, hemoglobin level, and prior coronary artery bypass graft surgery were associated with lower risk of death. C-index for the development cohort was 0.93 (95% CI, 0.92-0.94) and for the 2019 validation cohort and the site validation cohort was 0.87 (95% CI, 0.83-0.92) and 0.86 (95% CI, 0.83-0.89), respectively. The positive likelihood ratio of predicting a mortality event in the top decile was 2.87% more accurate than the CathPCI mortality model. Inclusion of anatomic information in the model resulted in significant improvement in model performance (likelihood ratio test P<0.01). CONCLUSIONS This contemporary risk model accurately predicts 30-day post-PCI mortality using a combination of clinical and anatomic variables. This can be immediately implemented into clinical practice to promote personalized informed consent discussions and appropriate preparation for high-risk PCI cases.
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Affiliation(s)
- Jacob A Doll
- VA Puget Sound Health Care System, Seattle, WA (J.A.D.).,University of Washington, Seattle, WA (J.A.D.).,CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington DC (J.A.D., C.I.O., M.E.P., S.W.W.)
| | - Colin I O'Donnell
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington DC (J.A.D., C.I.O., M.E.P., S.W.W.).,Rocky Mountain Regional VA Medical Center, Aurora, CO (C.I.O., M.E.P., S.W.W.)
| | - Meg E Plomondon
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington DC (J.A.D., C.I.O., M.E.P., S.W.W.).,Rocky Mountain Regional VA Medical Center, Aurora, CO (C.I.O., M.E.P., S.W.W.)
| | - Stephen W Waldo
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington DC (J.A.D., C.I.O., M.E.P., S.W.W.).,Rocky Mountain Regional VA Medical Center, Aurora, CO (C.I.O., M.E.P., S.W.W.).,University of Colorado School of Medicine, Aurora (S.W.W.)
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13
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Doll JA, Nelson AJ, Kaltenbach LA, Wojdyla D, Waldo SW, Rao SV, Wang TY. Percutaneous Coronary Intervention Operator Profiles and Associations With In-Hospital Mortality. Circ Cardiovasc Interv 2021; 15:e010909. [PMID: 34847693 DOI: 10.1161/circinterventions.121.010909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary intervention is performed by operators with differing experience, technique, and case mix. It is unknown if operator practice patterns impact patient outcomes. We sought to determine if a cluster algorithm can identify distinct profiles of percutaneous coronary intervention operators and if these profiles are associated with patient outcomes. METHODS Operators performing at least 25 annual procedures between 2014 and 2018 were clustered using an agglomerative hierarchical clustering algorithm. Risk-adjusted in-hospital mortality was compared between clusters. RESULTS We identified 4 practice profiles among 7706 operators performing 2 937 419 procedures. Cluster 1 (n=3345) demonstrated case mix and practice patterns similar to the national median. Cluster 2 (n=1993) treated patients with lower clinical acuity and were less likely to use intracoronary diagnostics, atherectomy, and radial access. Cluster 3 (n=1513) had the lowest case volume, were more likely to work at rural hospitals, and cared for a higher proportion of patients with ST-segment-elevation myocardial infarction and cardiogenic shock. Cluster 4 (n=855) had the highest case volume, were most likely to treat patients with high anatomic complexity and use atherectomy, intracoronary diagnostics, and mechanical support. Compared with cluster 1, adjusted in-hospital mortality was similar for cluster 2 (estimated difference, -0.03 [95% CI, -0.10 to 0.04]), higher for cluster 3 (0.14 [0.07-0.22]), and lower for cluster 4 (-0.15 [-0.24 to -0.06]). CONCLUSIONS Distinct percutaneous coronary intervention operator profiles are differentially associated with patient outcomes. A phenotypic approach to physician assessment may provide actionable feedback for quality improvement.
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Affiliation(s)
- Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington (J.A.D.).,Section of Cardiology, VA Puget Sound Health Care System, Seattle, WA (J.A.D.)
| | - Adam J Nelson
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Daniel Wojdyla
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Stephen W Waldo
- University of Colorado School of Medicine (S.W.W.).,Department of Medicine, Rocky Mountain Regional VA Medical Center (S.W.W.).,VA CART Program, VHA Office of Quality and Patient Safety (S.W.W.)
| | - Sunil V Rao
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.).,Department of Medicine, Duke University School of Medicine (S.V.R., T.Y.W.)
| | - Tracy Y Wang
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.).,Department of Medicine, Duke University School of Medicine (S.V.R., T.Y.W.)
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14
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Elkaryoni A, Elgendy IY, Manshad A, Desai N, Liu JC, Syed M, Leya FS, Lewis BE, Steen LH, Lopez JJ, Darki A. Trends and Outcomes of Transferred Patients With ST-Elevation Myocardial Infarction from Acute Care Hospitals (from a Nationwide Analysis). Am J Cardiol 2021; 160:129-130. [PMID: 34610871 DOI: 10.1016/j.amjcard.2021.08.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
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15
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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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16
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Schopfer DW. Rural health disparities in chronic heart disease. Prev Med 2021; 152:106782. [PMID: 34499971 DOI: 10.1016/j.ypmed.2021.106782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/02/2021] [Accepted: 09/04/2021] [Indexed: 01/02/2023]
Abstract
Rural communities suffer from significant disparities in cardiovascular health. The reasons for worse cardiovascular health and outcomes is due to a number of factors including economic, educational, and healthcare access. This commentary draws attention to these challenges and highlights how telemedicine may reduce a portion of this gap. In particular, an opportunity to modify cardiac rehabilitation programs to include a remotely-administered model using telemedicine is a novel method that holds promise.
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17
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Yildiz M, Wade SR, Henry TD. STEMI care 2021: Addressing the knowledge gaps. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 11:100044. [PMID: 34664037 PMCID: PMC8515361 DOI: 10.1016/j.ahjo.2021.100044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/27/2022]
Abstract
Tremendous progress has been made in the treatment of ST-segment elevation myocardial infarction (STEMI), the most severe and time-sensitive acute coronary syndrome. Primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion, which has stimulated the development of regional STEMI systems of care with standardized protocols designed to optimize care. However, challenges remain for patients with cardiogenic shock, out-of-hospital cardiac arrest, an expected delay to reperfusion (>120 min), in-hospital STEMI, and more recently, those with Covid-19 infection. Ultimately, the goal is to provide timely reperfusion with primary PCI coupled with the optimal antiplatelet and anticoagulant therapies. We review the challenges and provide insights into the remaining knowledge gaps for contemporary STEMI care.
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Key Words
- CCL, cardiac catheterization laboratory
- CS, cardiogenic shock
- Cangrelor
- Cardiogenic shock
- Covid-19
- Covid-19, coronavirus disease 2019
- DAPT, dual antiplatelet therapy
- EMS, emergency medical service
- MCS, mechanical circulatory support
- OHCA, out-of-hospital cardiac arrest
- Out-of-hospital cardiac arrest
- PCI, percutaneous coronary intervention
- Regional systems
- SARS-CoV-2, severe acute respiratory syndrome coronavirus-2
- ST-segment elevation myocardial infarction
- STEMI, ST-segment elevation myocardial infarction
- TH, therapeutic hypothermia
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Affiliation(s)
- Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America
| | - Spencer R. Wade
- Department of Internal Medicine at The Christ Hospital, Cincinnati, OH, United States of America
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America,Corresponding author at: The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital Health Network, 2123 Auburn Avenue Suite 424, Cincinnati, OH 45219, United States of America
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18
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Alvarez Villela M, Clark R, William P, Sims DB, Jorde UP. Systems of Care in Cardiogenic Shock. Front Cardiovasc Med 2021; 8:712594. [PMID: 34616782 PMCID: PMC8489379 DOI: 10.3389/fcvm.2021.712594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/26/2021] [Indexed: 12/17/2022] Open
Abstract
Outcomes for cardiogenic shock (CS) patients remain relatively poor despite significant advancements in primary percutaneous coronary interventions (PCI) and temporary circulatory support (TCS) technologies. Mortality from CS shows great disparities that seem to reflect large variations in access to care and physician practice patterns. Recent reports of different models to standardize care in CS have shown considerable potential at improving outcomes. The creation of regional, integrated, 3-tiered systems, would facilitate standardized interventions and equitable access to care. Multidisciplinary CS teams at Level I centers would direct care in a hub-and-spoke model through jointly developed protocols and real-time shared decision making. Levels II and III centers would provide early access to life-saving therapies and safe transfer to designated hub centers. In regions with large geographical distances, the implementation of telemedicine-cardiac intensive care unit (CICU) care can be an important resource for the creation of effective systems of care.
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Affiliation(s)
- Miguel Alvarez Villela
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States.,Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY, United States
| | - Rachel Clark
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States
| | - Preethi William
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States.,Division of Cardiology, Banner University Medical Center, Tucson, University of Arizona, Tucson, AZ, United States
| | - Daniel B Sims
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States
| | - Ulrich P Jorde
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, United States
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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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Tummala R, Shah SD, Rawal E, Sandhu RK, Kavuri SP, Kaur G, Khan AT, Mathialagan K, Ajibawo T. In-Hospital Mortality Risk Factor Analysis in Multivessel Percutaneous Coronary Intervention Inpatient Recipients in the United States. Cureus 2021; 13:e17520. [PMID: 34603890 PMCID: PMC8476197 DOI: 10.7759/cureus.17520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives The primary goal of our study is to evaluate the mortality rate in inpatient recipients of multivessel percutaneous coronary intervention (MVPCI) and to evaluate the demographic risk factors and medical complications that increase the risk of in-hospital mortality. Methods We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS, 2016) and included 127,145 inpatients who received MVPCI as a primary procedure in United States' hospitals. We used a multivariable logistic regression model adjusted for demographic confounders to measure the odds ratio (OR) of association of medical complications and in-hospital mortality risk in MVPCI recipients. Results The in-hospital mortality rate was 2% in MVPCI recipients and was seen majorly in older-age adults (>64 years, 74%) and males (61%). Even though the prevalence of mortality among females was comparatively low, yet in the regression model, they were at a higher risk for in-hospital mortality than males (OR 1.2; 95% CI 1.13-1.37). While comparing ethnicities, in-hospital mortality was prevalent in whites (79%) followed by blacks (9%) and Hispanics (7.5%). Patients who developed cardiogenic shock were at higher odds of in-hospital mortality (OR 9.2; 95% CI 8.27-10.24) followed by respiratory failure (OR 5.9; 95% CI 5.39-6.64) and ventricular fibrillation (OR 3.5; 95% CI 3.18-3.92). Conclusion Accelerated use of MVPCI made it important to study in-hospital mortality risk factors allowing us to devise strategies to improve the utilization and improve the quality of life of these at-risk patients. Despite its effectiveness and comparatively lower mortality profile, aggressive usage of MVPCI is restricted due to the periprocedural complications and morbidity profile of the patients.
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Affiliation(s)
- Ravi Tummala
- Internal Medicine, Narayana Medical College, Nellore, IND
| | - Suchi D Shah
- Internal Medicine, Ahmedabad Municipal Corporation's Medical Education Trust Medical College, Ahmedabad, IND
| | - Era Rawal
- Cardiology, Norvic International Hospital, Kathmandu, NPL
| | - Ramneek K Sandhu
- Internal Medicine, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, IND
| | - Swathi P Kavuri
- Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Gagan Kaur
- Surgery, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, IND
| | - Asma T Khan
- Internal Medicine, Larkin Community Hospital, South Miami, USA
| | | | - Temitope Ajibawo
- Internal Medicine, Brookdale University Hospital Medical Center, New York City, USA
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21
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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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22
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Sturm RC, Jones TL, Youngquist ST, Shah RU. Regional Systems of Care in ST Elevation Myocardial Infarction. Interv Cardiol Clin 2021; 10:281-291. [PMID: 34053615 DOI: 10.1016/j.iccl.2021.03.001] [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] [Indexed: 06/12/2023]
Abstract
ST-segment elevation myocardial infarction is a medical emergency with significant health care delivery challenges to ensure rapid triage and treatment. Several developments over the past decades have led to improved care delivery, decreased time to reperfusion, and decreased mortality. Still, significant challenges remain to further optimize the delivery of care for this patient population.
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Affiliation(s)
- Robert C Sturm
- Division of Cardiovascular Medicine, University of Utah, 30 N. 1900 E, Room 4A100, Salt Lake City, UT, 84132, USA.
| | - Tara L Jones
- Division of Cardiovascular Medicine, University of Utah, 30 N. 1900 E, Room 4A100, Salt Lake City, UT, 84132, USA
| | - Scott T Youngquist
- Division of Emergency Medicine, University of Utah, 30 N 1900 E 1C026, Salt Lake City, UT 84132, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah, 30 N. 1900 E, Room 4A100, Salt Lake City, UT, 84132, USA
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23
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Singer J, VanOosterhout S, Madder R. Remote robotic endovascular thrombectomy for acute ischaemic stroke. BMJ Neurol Open 2021; 3:e000141. [PMID: 34263168 PMCID: PMC8246369 DOI: 10.1136/bmjno-2021-000141] [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] [Accepted: 05/27/2021] [Indexed: 11/04/2022] Open
Abstract
Background In acute ischaemic stroke, endovascular thrombectomy (ET) significantly reduces disability compared with thrombolytic therapy, but access to ET is currently limited. Leveraging telerobotic technology to disseminate neurosurgical expertise could increase access to ET. This proof-of-concept evaluation was performed to determine whether remote robotic ET (RRET), wherein an offsite neurosurgeon and an onsite interventional cardiologist collaboratively use telerobotics to perform ET, is technically feasible. Methods An ex vivo model of RRET was constructed by establishing a network connection between a robotic drive in a simulation laboratory and a robotic control unit 5 miles away. Using onsite assistance from an interventional cardiologist in the simulation laboratory, an offsite neurosurgeon used the robotic controls to attempt RRET on a fluid-filled silicone model of human vasculature containing simulated thrombus material in the left middle cerebral artery (MCA). Results From the offsite location 5 miles away, the neurosurgeon used the robotic system to successfully navigate a guidewire from the carotid artery to simulated thrombus in the MCA. Under the direction of the neurosurgeon, the onsite interventional cardiologist then successfully manually advanced an aspiration catheter over the guidewire to the thrombus, removed the guidewire and performed aspiration. Conclusions In this proof-of-concept evaluation, the technical feasibility of RRET was demonstrated in an ex vivo model and was collaboratively performed by an offsite neurosurgeon and an onsite interventional cardiologist. This report supports the design of future studies to determine if RRET could be used to increase access to ET for patients with acute ischaemic stroke.
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Affiliation(s)
- Justin Singer
- Neurosurgery, Spectrum Health, Grand Rapids, Michigan, USA
| | | | - Ryan Madder
- Cardiology, Spectrum Health, Grand Rapids, Michigan, USA
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24
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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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25
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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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Damluji AA, Fabbro M, Epstein RH, Rayer S, Wang Y, Moscucci M, Cohen MG, Carroll JD, Messenger JC, Resar JR, Cohen DJ, Sherwood MW, O'Connor CM, Batchelor W. Transcatheter Aortic Valve Replacement in Low-Population Density Areas: Assessing Healthcare Access for Older Adults With Severe Aortic Stenosis. Circ Cardiovasc Qual Outcomes 2020; 13:e006245. [PMID: 32813564 DOI: 10.1161/circoutcomes.119.006245] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Restricting transcatheter aortic valve replacement (TAVR) to centers based on volume thresholds alone can potentially create unintended disparities in healthcare access. We aimed to compare the influence of population density in state of Florida in regard to access to TAVR, TAVR utilization rates, and in-hospital mortality. METHODS AND RESULTS From 2011 to 2016, we used data from the Agency for Health Care Administration to calculate travel time and distance for each TAVR patient by comparing their home address to their TAVR facility ZIP code. Travel time and distance, TAVR rates, and mortality were compared across categories of low to high population density (population per square miles of land). Of the 6531 patients included, the mean (SD) age was 82 (9) years, 43% were female and 91% were White. Patients residing in the lowest category (<50/square miles) were younger, more likely to be men, and less likely to be a racial minority. Those residing in the lowest category density faced a longer unadjusted driving distances and times to their TAVR center (mean extra distance [miles]=43.5 [95% CI, 35.6-51.4]; P<0.001; mean extra time (minutes)=45.6 [95% CI, 38.3-52.9], P<0.001). This association persisted regardless of the methods used to determine population density. Excluding uninhabitable land, there was a 7-fold difference in TAVR utilization rates in the lowest versus highest population density regions (7 versus 45 per 100 000, P-for-pairwise-comparisons <0.001) and increase in TAVR in-hospital mortality (adjusted OR, 6.13 [95% CI, 1.97-19.1]; P<0.001). CONCLUSIONS Older patients living in rural counties in Florida face (1) significantly longer travel distances and times for TAVR, (2) lower TAVR utilization rates, and (3) higher adjusted TAVR mortality. These findings suggest that there are trade-offs between access to TAVR, its rate of utilization, and procedural mortality, all of which are important considerations when defining institutional and operator requirements for TAVR across the country.
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Affiliation(s)
- Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D., M.W.S., C.M.O., W.B.).,Division of Cardiology, Johns Hopkins University, Baltimore, MD (A.A.D., J.R.R.)
| | - Michael Fabbro
- Department of Anesthesiology, University of Miami, FL (M.F., R.H.E.)
| | - Richard H Epstein
- Department of Anesthesiology, University of Miami, FL (M.F., R.H.E.)
| | - Stefan Rayer
- Bureau of Economic and Business Research, University of Florida, Gainesville, FL (S.R., Y.W.)
| | - Ying Wang
- Bureau of Economic and Business Research, University of Florida, Gainesville, FL (S.R., Y.W.)
| | | | | | - John D Carroll
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO (J.D.C., J.C.M.)
| | - John C Messenger
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO (J.D.C., J.C.M.)
| | - Jon R Resar
- Division of Cardiology, Johns Hopkins University, Baltimore, MD (A.A.D., J.R.R.)
| | - David J Cohen
- University of Missouri-Kansas City School of Medicine, Kansas City, MO (D.J.C.)
| | - Matthew W Sherwood
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D., M.W.S., C.M.O., W.B.)
| | - Christopher M O'Connor
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D., M.W.S., C.M.O., W.B.)
| | - Wayne Batchelor
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D., M.W.S., C.M.O., W.B.)
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27
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Khan SA, Bhattacharjee S, Ghani MOA, Walden R, Chen QM. Vitamin C for Cardiac Protection during Percutaneous Coronary Intervention: A Systematic Review of Randomized Controlled Trials. Nutrients 2020; 12:E2199. [PMID: 32718091 PMCID: PMC7468730 DOI: 10.3390/nu12082199] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 12/28/2022] Open
Abstract
Percutaneous coronary intervention (PCI) is the preferred treatment for acute coronary syndrome (ACS) secondary to atherosclerotic coronary artery disease. This nonsurgical procedure is also used for selective patients with stable angina. Although the procedure is essential for restoring blood flow, reperfusion can increase oxidative stress as a side effect. We address whether intravenous infusion of vitamin C (VC) prior to PCI provides a benefit for cardioprotection. A total of eight randomized controlled trials (RCT) reported in the literature were selected from 371 publications through systematic literature searches in six electronic databases. The data of VC effect on cardiac injury biomarkers and cardiac function were extracted from these trials adding up to a total of 1185 patients. VC administration reduced cardiac injury as measured by troponin and CK-MB elevations, along with increased antioxidant reservoir, reduced reactive oxygen species (ROS) and decreased inflammatory markers. Improvement of the left ventricular ejection fraction (LVEF) and telediastolic left ventricular volume (TLVV) showed a trend but inconclusive association with VC. Intravenous infusion of VC before PCI may serve as an effective method for cardioprotection against reperfusion injury.
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Affiliation(s)
- Sher Ali Khan
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, 1295 N. Martin Ave, Tucson, AZ 85721, USA; (S.A.K.); (S.B.)
| | - Sandipan Bhattacharjee
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, 1295 N. Martin Ave, Tucson, AZ 85721, USA; (S.A.K.); (S.B.)
| | | | - Rachel Walden
- Annette and Irwin Eskind Family Biomedical Library, Jean & Alexander Heard Libraries, Vanderbilt University, Nashville, TN 37203, USA;
| | - Qin M. Chen
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, 1295 N. Martin Ave, Tucson, AZ 85721, USA; (S.A.K.); (S.B.)
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28
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Deng J, Lu Y, Ou J, Shao X, Wang X, Xie H. Remote Ischemic Preconditioning Reduces the Risk of Contrast-Induced Nephropathy in Patients with Moderate Renal Impairment Undergoing Percutaneous Coronary Angiography: A Meta-Analysis. Kidney Blood Press Res 2020; 45:549-564. [PMID: 32688358 DOI: 10.1159/000507330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/18/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS This meta-analysis evaluated the effects of remote ischemic preconditioning (RIPC) on the risk of contrast-induced nephropathy (CIN) in patients undergoing percutaneous coronary intervention/coronary angiography (PCI/CA). METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that assessed the effect of RIPC on CIN in patients undergoing PCI/CA. The main outcomes of interest were the incidence of CIN 48-72 h after CA, the levels of serum creatinine, cystatin C, neutrophil gelatinase-associated lipocalin, and estimated glomerular filtration rate (eGFR), mortality, and requirement of hemodialysis and rehospitalization. The analysis was conducted using the random-effect model due to the expected heterogeneity among different studies. RESULTS In total, 16 trials covering 2,048 patients were identified. By assessing the methodological quality of the included studies through the Coch-rane risk of bias, we found that of the 16 RCTs, 3 had a low risk of bias, 6 a high, and 7 an unclear risk. The application of RIPC decreased the incidence of CIN (relative risk, RR, 0.50, 95% confidence interval, CI, 0.39-0.65; p < 0.001). Subgroup analyses showed that RIPC decreased the incidence of CIN in patients with eGFR <60 mL/min/1.73 m2 (RR 0.53, 95% CI 0.38-0.75; p < 0.001) but not in patients with eGRF ≥60 mL/min/1.73 m2 (RR 0.82, 95% CI 0.35-1.94; p = 0.66) at baseline. Furthermore, the increase in serum creatinine was significantly lower in patients with RIPC compared to control patients (standardized mean difference -1.41, 95% CI -2.46 to -0.35; p = 0.009). CONCLUSIONS Based on 16 RCTs, this meta-analysis shows that RIPC can reduce the risk of CIN in patients with moderate renal impairment undergoing PCI/CA. However, this needs to be confirmed by further high-quality evidence.
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Affiliation(s)
- Jin Deng
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China,
| | - Yi Lu
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Jihong Ou
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Xiaofei Shao
- Department of Nephrology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Xin Wang
- Department of Nephrology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Hongping Xie
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
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Care and outcomes of urban and non-urban out-of-hospital cardiac arrest patients during the HeartRescue Project in Washington state and North Carolina. Resuscitation 2020; 152:5-15. [PMID: 32430288 DOI: 10.1016/j.resuscitation.2020.04.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 04/14/2020] [Accepted: 04/23/2020] [Indexed: 11/20/2022]
Abstract
AIM We examined overall and temporal differences in out-of-hospital cardiac arrest (OHCA) care and outcomes by urban versus non-urban setting separately for North Carolina (NC) and Washington State (WA) during HeartRescue initiatives and associations of urban/non-urban settings with outcome by state. METHODS OHCAs of presumed cardiac etiology from counties with complete registry enrollment in NC during 2010-2014 (catchment population = 3,143,809) and WA during 2011-2014 (catchment population = 3,653,506) were identified. Geospatial arrest location data and US Census classification were used to categorize urban areas with ≥50,000 versus non-urban <50,000 people. RESULTS Included were 7731 NC cases (78.9% urban) and 4472 WA cases (85.8% urban). Bystander cardiopulmonary resuscitation (CPR) increased from 36.9% (2010) to 50.3% (2014) in NC non-urban areas versus 58.2% (2011) to 69.2% (2014) in WA; and from 39.3% to 51.1% in NC urban areas versus 52.4% to 61.8% in WA. Crude discharge survival odds ratio (OR) was 2.49 (95%CI 1.96-3.16) for urban versus non-urban NC cases not declared dead in field (N = 4241). Adjusted for age, sex, public location, bystander-witness status, time between emergency call and emergency medical service (EMS) arrival, calendar-year, bystander and first-responder CPR and defibrillation and direct PCI-center transport, OR was 1.30 (95%CI 0.98-1.73). In WA, corresponding crude and adjusted ORs were 1.38 (95%CI 0.99-1.93) and 1.46 (95%CI 1.00-2.13). In both states, bystander and first-responder CPR and defibrillation and direct PCI-hospital transport were associated with increased survival. CONCLUSIONS During HeartRescue initiatives, bystander CPR increased in urban and non-urban locations. Bystander and first-responder interventions and direct PCI-hospital transport were associated with improved outcomes, including in non-urban areas.
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30
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Garcia S, Schmidt CW, Garberich R, Henry TD, Bradley SM, Brilakis ES, Burke N, Chavez IJ, Eckman P, Gössl M, Mooney MR, Newell MC, Poulose AK, Sorajja P, Traverse JH, Wang YL, Sharkey SW. Temporal changes in patient characteristics and outcomes in ST-segment elevation myocardial infarction 2003-2018. Catheter Cardiovasc Interv 2020; 97:1109-1117. [PMID: 32294799 DOI: 10.1002/ccd.28901] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/29/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND We sought to describe changes in demographic variables, process of care measures, and outcomes of patients treated in a regional ST-segment elevation myocardial infarction (STEMI) program over the last 15 years. METHODS We describe demographic variables, process of care measures, and outcomes of patients treated in the program in various 5-year time periods: 2003-2007 (n = 1,821), 2008-2012 (n = 1,968), and 2013-2018 (n = 2,223). The primary outcome measures were in-hospital and 30-day mortality. RESULTS Among 6,012 STEMI patients treated from 2003 to 2018 we observed a significant increase in mean age at presentation (62 ± 14 to 64 ± 13 years) and diabetes (14-22%, p < .01). The proportion of patients with cardiogenic shock (CS) and cardiac arrest (CA) pre-PCI increased significantly from 9.5% to 11.1% and 8.5% to 12.7% (p < .05), respectively. The median door-to-balloon (D2B) times decreased from 98 to 93 min and total ischemic time decreased from 202 to 185 min (all p < .05). Despite increased patient complexity, the proportion of nontransfer and transfer patients achieving D2B times consistent with guideline recommendations remained unchanged (for nontransfer patients 79-82%, p = .45 and for transfer patients 65-64%, p = .34). Among all STEMI patients, in-hospital mortality increased during the study period from 4.9 to 6.9% (p = .007) but remained stable (<2%) when CA and CS patients were excluded. CONCLUSIONS Over the last 15 years, short-term STEMI mortality has increased despite improvements in care delivery metrics. Patients with CA and/or CS now represent 10% of STEMI patients and are responsible for 80% of deaths. Therefore, efforts to improve STEMI mortality, and metrics for assessing STEMI programs, should focus on these patients.
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Affiliation(s)
- Santiago Garcia
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Christian W Schmidt
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ross Garberich
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
| | - Steven M Bradley
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Nickolas Burke
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ivan J Chavez
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Peter Eckman
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Mario Gössl
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Michael R Mooney
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Marc C Newell
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Anil K Poulose
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Paul Sorajja
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Jay H Traverse
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Yale L Wang
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Scott W Sharkey
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
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Yasaitis LC, Guan J, Ko DT, Chandra A, Stukel TA. Cardiac intervention rates for older patients with acute myocardial infarction in the United States and Ontario, 2003-2013: a retrospective cohort study. CMAJ Open 2020; 8:E437-E447. [PMID: 32527795 PMCID: PMC7850174 DOI: 10.9778/cmajo.20190190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Previous work showed lower cardiac intervention rates for patients with acute myocardial infarction (AMI) in Ontario than in the United States. We assessed whether Ontario's efforts to improve access to rapid percutaneous coronary intervention (PCI) for AMI were associated with improved timeliness of care and whether this closed the gap between the 2 jurisdictions. METHODS In this retrospective cohort study, we followed adults aged 66-99 years in the US and Ontario for 30 days after admission for incident AMI between 2003 and 2013 using health administrative data from both countries. We calculated the proportion of patients who received cardiac catheterization, PCI and coronary artery bypass grafting on the day of and within 30 days of admission overall and according to AMI type (ST-segment elevation AMI [STEMI] v. non-STEMI) and risk group (low, medium or high predicted risk of 30-d mortality). RESULTS We followed 414 216 patients in the US and 112 484 in Ontario. The large disparities in cardiac intervention rates observed in 2003 mostly disappeared over time. By 2013, the proportion of patients who received same-day PCI was only slightly higher in the US than in Ontario (22.3% v. 19.2%), whereas the converse was true for 30-day PCI (44.0% v. 41.3%). In 2013, patients with STEMI in the US and Ontario received PCI at nearly identical rates on the day of admission (66.3% v. 63.8%); however, more patients at high risk with STEMI in the US than in Ontario received PCI, both on the day of admission (55.5% v. 44.7%) and by 30 days (60.5% v. 55.0%). INTERPRETATION Despite differences in resources and organization of delivery systems, by 2013, timely receipt of PCI by Ontario patients with AMI lagged only slightly behind that by US patients. A higher supply of PCI centres in the US may have facilitated earlier intervention among patients at high risk with STEMI.
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Affiliation(s)
- Laura C Yasaitis
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Jun Guan
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Dennis T Ko
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Amitabh Chandra
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Therese A Stukel
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
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Grundmann F, Müller RU, Hoyer-Allo KJR, Späth MR, Passmann E, Becker I, Pfister R, Baldus S, Benzing T, Burst V. Dietary restriction for prevention of contrast-induced acute kidney injury in patients undergoing percutaneous coronary angiography: a randomized controlled trial. Sci Rep 2020; 10:5202. [PMID: 32251303 PMCID: PMC7089976 DOI: 10.1038/s41598-020-61895-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/04/2020] [Indexed: 01/25/2023] Open
Abstract
Short-term dietary restriction (DR) may prevent organ damage from ischemic or toxic insults in animals, but clear evidence in humans is missing. While especially intraarterial administration of contrast media represents a cause of hospital-acquired acute kidney injury (AKI), targeted preventive strategies are not available. This trial investigated the feasibility and effectiveness of pre-interventional DR for preventing AKI in patients undergoing percutaneous coronary intervention (PCI). Patients were randomized to receive a formula diet containing 60% of daily energy requirement (DR group) or ad-libitum food during the 4-day-interval before PCI. Primary endpoint was change of serum creatinine 48 h after PCI (Δcreatinine). Further analyses included incidence of AKI and safety evaluation. Δcreatinine post PCI in the DR group vs. the control group did not show any difference (DR: 0.03(-0.15,0.14)mg/dL vs. control: 0.09(-0.03,0.22)mg/dL;p = 0.797). Subgroup analyses revealed a significant beneficial impact of DR in patients that received ≤100 ml of contrast agent (DR n = 26: Δcreatinine -0.03(-0.20,0.08)mg/dL vs. control n = 24: Δcreatinine 0.10(-0.08,0.24)mg/dL; p = 0.041) and in patients with ≤2 risk factors for AKI (DR: n = 27; Δcreatinine -0.01(-0.18,0.07)mg/dL vs. control n = 31: Δcreatinine 0.09(-0.03,0.16)mg/dl; p = 0.030). Although the primary endpoint was not met, the results of this trial suggest a beneficial impact of DR in low-to-moderate risk patients.
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Affiliation(s)
- Franziska Grundmann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | - Roman-Ulrich Müller
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Systems Biology of Ageing Cologne, University of Cologne, Cologne, Germany
| | - Karla Johanna Ruth Hoyer-Allo
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Martin Richard Späth
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Eva Passmann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Roman Pfister
- Department III of Internal Medicine, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Stephan Baldus
- Department III of Internal Medicine, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Thomas Benzing
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Systems Biology of Ageing Cologne, University of Cologne, Cologne, Germany
| | - Volker Burst
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, Hipp J, Konig M, Sanchez E, Joynt Maddox KE. Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation 2020; 141:e615-e644. [PMID: 32078375 DOI: 10.1161/cir.0000000000000753] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.
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Characterization of Polysaccharides Extracted from Sargassum fusiforme and Its Effective Prevention of Contrast-Induced Nephropathy via Enhancing Antioxidant Capacity. INT J POLYM SCI 2019. [DOI: 10.1155/2019/9035818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Contrast-induced nephropathy (CIN) is a common complication in patients with coronary arteriography, and oxidative stress is involved in the CIN pathogenesis. Sargassum fusiforme (SF) is a brown seaweed with medicinal value, and its polysaccharides have good antioxidant activity. In this study, the crude polysaccharides (cSFP-C) were extracted by cold water, precipitated by ethanol, purified by CaCl2, and detected with high contents of sulfate radical and fucose. cSFP-C is composed of glucose, glucuronic acid, xylose, rhamnose, mannose, galactose, and fucose with a molar ratio of 1.0 : 0.4 : 5.6 : 1.2 : 1.7 : 12.3 : 56.1. The cSFP-C has the typical absorption of polysaccharides. Antioxidation assays in vitro showed that cSFP-C exhibited superoxide radical scavenging activity which was better than the hot water-extracted crude polysaccharides (cSFP-H). 20 rats were divided into 4 groups (n=5): sham group; CIN group; CIN+cSFP-C group, and cSFP-C group. The CIN+cSFP-C group and cSFP-C group were pretreated intragastrically with cSFP-C at a dose of 9.45 g/kg twice daily for 5 consecutive days. Then, the CIN group and CIN+cSFP-C group were given indomethacin to develop CIN. The in vivo results showed that cSFP-C could decrease blood creatinine and urea nitrogen, inhibiting pathological injury in the renal tissues. The MDA content of renal tissues was decreased, while the activity of SOD was increased. The crude sulfated polysaccharides extracted from S. fusiforme have a renoprotective effect on oxidative stress to alleviate the kidney injury in CIN rats.
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Arora S, Stouffer GA, Kucharska-Newton A, Vaduganathan M, Qamar A, Matsushita K, Kolte D, Reynolds HR, Bangalore S, Rosamond WD, Bhatt DL, Caughey MC. Fifteen-Year Trends in Management and Outcomes of Non-ST-Segment-Elevation Myocardial Infarction Among Black and White Patients: The ARIC Community Surveillance Study, 2000-2014. J Am Heart Assoc 2019; 7:e010203. [PMID: 30371336 PMCID: PMC6404893 DOI: 10.1161/jaha.118.010203] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [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 Standardization of evidence‐based medical therapies has improved outcomes for patients with non–ST‐segment–elevation myocardial infarction (NSTEMI). Although racial differences in NSTEMI management have previously been reported, it is uncertain whether these differences have been ameliorated over time. Methods and Results The ARIC (Atherosclerosis Risk in Communities) Community Surveillance study conducts hospital surveillance of acute myocardial infarction in 4 US communities. NSTEMI was classified by physician review, using a validated algorithm. From 2000 to 2014, 17 755 weighted hospitalizations for NSTEMI (patient race: 36% black, 64% white) were sampled by ARIC. Black patients were younger (aged 60 versus 66 years), more often female (45% versus 38%), and less likely to have medical insurance (88% versus 93%) but had more comorbidities. Black patients were less often administered aspirin (85% versus 92%), other antiplatelet therapy (45% versus 60%), β‐blockers (85% versus 88%), and lipid‐lowering medications (68% versus 76%). After adjustments, black patients had a 24% lower probability of receiving nonaspirin antiplatelets (relative risk: 0.76; 95% confidence interval, 0.71–0.81), a 29% lower probability of angiography (relative risk: 0.71; 95% confidence interval, 0.67–0.76), and a 45% lower probability of revascularization (relative risk: 0.55; 95% confidence interval, 0.50–0.60). No suggestion of a changing trend over time was observed for any NSTEMI therapy (P values for interaction, all >0.20). Conclusions This longitudinal community surveillance of hospitalized NSTEMI patients suggests black patients have more comorbidities and less likelihood of receiving guideline‐based NSTEMI therapies, and these findings persisted across the 15‐year period. Focused efforts to reduce comorbidity burden and to more consistently implement guideline‐directed treatments in this high‐risk population are warranted.
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Affiliation(s)
- Sameer Arora
- 1 Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
| | - George A Stouffer
- 1 Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
| | - Anna Kucharska-Newton
- 2 Department of Epidemiology University of North Carolina Gillings School of Global Public Health Chapel Hill NC
| | - Muthiah Vaduganathan
- 3 Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School Boston MA
| | - Arman Qamar
- 3 Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School Boston MA
| | - Kunihiro Matsushita
- 4 Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD.,5 Division of Cardiology Johns Hopkins School of Medicine Baltimore MD
| | - Dhaval Kolte
- 6 Division of Cardiology Warren Alpert Medical School of Brown University Providence RI
| | - Harmony R Reynolds
- 7 Division of Cardiology New York University School of Medicine New York NY
| | - Sripal Bangalore
- 7 Division of Cardiology New York University School of Medicine New York NY
| | - Wayne D Rosamond
- 2 Department of Epidemiology University of North Carolina Gillings School of Global Public Health Chapel Hill NC
| | - Deepak L Bhatt
- 3 Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School Boston MA
| | - Melissa C Caughey
- 1 Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
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Fiorilli PN, Kolansky DM. Getting to the Right Place at the Right Time: Another Piece of the STEMI Puzzle. Circ Cardiovasc Interv 2019; 11:e006700. [PMID: 29716934 DOI: 10.1161/circinterventions.118.006700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul N Fiorilli
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Daniel M Kolansky
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia.
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Hospital mortality and thirty day readmission among patients with non-acute myocardial infarction related cardiogenic shock. Int J Cardiol 2018; 270:60-67. [DOI: 10.1016/j.ijcard.2018.06.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 05/02/2018] [Accepted: 06/08/2018] [Indexed: 12/16/2022]
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Doi M, Fukahori H, Oyama Y, Morita K. Factors associated with depressive symptoms in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A prospective cohort study. Nurs Open 2018; 5:583-592. [PMID: 30338104 PMCID: PMC6178357 DOI: 10.1002/nop2.171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 04/24/2018] [Accepted: 05/21/2018] [Indexed: 01/22/2023] Open
Abstract
AIM To identify the association between possible factors and depression among post-percutaneous coronary intervention patients with acute coronary syndrome. DESIGN Prospective cohort study. METHODS Sixty-eight post-percutaneous coronary intervention patients with acute coronary syndrome were enrolled between January 2016 - June 2017. The Hospital Anxiety and Depression Scale scores at 1-3 months after discharge were regressed onto uncertainty in illness and other clinical factors based on the Roy Adaptation Model. RESULTS Thirty-six patients were included in the final analysis. Higher baseline depression scores, higher changes in uncertainty in illness and feeling annoyed by troublesome tasks after discharge were associated with higher depressive scores at 1 month after discharge. Careful observation and support of patients' ineffective responses in self-concept mode may be effective in preventing depression.
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Affiliation(s)
- Mana Doi
- Graduate School of Health Care SciencesTokyo Medical and Dental UniversityTokyoJapan
- Nursing Course, School of MedicineYokohama City UniversityYokohamaJapan
| | - Hiroki Fukahori
- Graduate School of Health Care SciencesTokyo Medical and Dental UniversityTokyoJapan
- Faculty of Nursing and Medical CareKeio UniversityKanagawaJapan
| | - Yumiko Oyama
- Nursing Course, School of MedicineYokohama City UniversityYokohamaJapan
| | - Kumiko Morita
- Graduate School of Health Care SciencesTokyo Medical and Dental UniversityTokyoJapan
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Developing a Rural, Community-Based Registry for Cardiovascular Quality Improvement. Qual Manag Health Care 2018; 27:209-214. [PMID: 30260928 DOI: 10.1097/qmh.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular disease is one of the leading causes of death, yet most evidence is collected from small clinical trials or individual hospital providers. Achieving scalable data to enable quality improvements (QIs) remains a challenge. We investigate whether a registry that is shared by multiple providers and integrates data longitudinally could help drive QIs across a large rural geographic region. METHODS We describe a case study involving the development of an informatics infrastructure across the entire state of Wyoming. This rural, regional, community-based cardiovascular system of care involved all interventional hospitals in the state as well as all surrounding states. Data exchange was initiated between 36 hospitals, and 56 ambulance agencies, to a centralized registry for clinical analytics and QI for patients with acute myocardial infarction. RESULTS After 3 years, the registry maintained all documented acute myocardial infarctions across Wyoming. Median total ischemic time (time from patient's symptom onset to definitive treatment) had a 36.7% improvement during the program. Changes in quality for the rural community included reduction in overall treatment times, as well as enhanced training, standardized protocols, and community awareness. We also share key lessons learned. CONCLUSIONS Collaborative data registries for emergency cardiovascular care can help providers and communities measure and improve the quality of the care across regions.
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Siddiqi TJ, Usman MS, Khan MS, Sreenivasan J, Kassas I, Riaz H, Raza S, Deo SV, Sharif H, Kalra A, Yadav N. Meta-Analysis Comparing Primary Percutaneous Coronary Intervention Versus Pharmacoinvasive Therapy in Transfer Patients with ST-Elevation Myocardial Infarction. Am J Cardiol 2018; 122:542-547. [PMID: 30205885 DOI: 10.1016/j.amjcard.2018.04.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 12/24/2022]
Abstract
ST-elevation myocardial infarction patients presenting at non-percutaneous coronary intervention (PCI)-capable hospitals often need to be transferred for primary percutaneous coronary intervention (PPCI). This increases time to revascularization, leading to increased risk of in-hospital mortality. With recent focus on total ischemic time rather than door-to-balloon time as the principal determinant of outcomes in ST-elevation myocardial infarction patients, pharmacoinvasive therapy (PIT) has gained attention as a possible improvement over PPCI in patients requiring transfer. Our objective was to observe how PIT stands against PPCI in terms of safety and efficacy. Electronic databases were searched for randomized controlled trials and observational studies comparing PPCI to PIT. PIT was defined as administration of thrombolytic drugs followed by immediate PCI only in case of failed thrombolysis. Results from studies were pooled using a random-effects model. We identified 17 relevant studies (6 randomized controlled trials, 11 observational studies) including 13,037 patients. Overall, there was no significant difference in short-term mortality (odds ratio [OR] = 1.20 [0.97 to 1.49]; I2 = 14.2%; p = 0.099); however, PIT significantly decreased short-term mortality (OR = 1.46 [1.08 to 1.96]; I2 = 0%; p = 0.01) in those studies with a symptom-onset-to-device time ≥200 minutes. There was a significantly lower risk reinfarction (OR = 0.69 [0.49 to 0.97]; I2 = 0%; p = 0.033) in the PPCI group, while the risk of cardiogenic shock was significantly higher (OR = 1.48 [1.13 to 1.94]; I2 = 0%; p = 0.005). In conclusion, PIT versus PPCI decisions should preferably be customized in patients presenting to non-PCI capable hospitals. Factors that need to be considered include symptom-onset to first medical contact time, expected time of transfer to a PCI-capable hospital, and patients risk factors.
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Affiliation(s)
| | | | | | | | - Ibrahim Kassas
- Division of Cardiology, New York University School of Medicine, New York, New York
| | - Haris Riaz
- Division of Cardiology, Cleveland Clinic, Cleveland Ohio
| | - Sajjad Raza
- Department of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Salil V Deo
- Department of Cardiac Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Hasanat Sharif
- Department of Cardiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Ankur Kalra
- Department of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Neha Yadav
- Division of Cardiology, John H Stroger Jr. Hospital of Cook County, Chicago, Illinois
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Brown CL, Henry TD. The Quandary of Volume! How Much Is Enough? Catheter Cardiovasc Interv 2018; 92:251-252. [PMID: 30230209 DOI: 10.1002/ccd.27782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 11/11/2022]
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Webner C. Discharging a Patient After a Percutaneous Coronary Intervention. Crit Care Nurse 2018; 38:80-81. [PMID: 29858199 DOI: 10.4037/ccn2018945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Cynthia Webner
- Cynthia Webner is a cardiac clinical nurse nurse practitioner, educator, and specialist, consultant in Northeast Ohio.
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Giacoppo D, Gargiulo G, Buccheri S, Aruta P, Byrne RA, Cassese S, Dangas G, Kastrati A, Mehran R, Tamburino C, Capodanno D. Preventive Strategies for Contrast-Induced Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Procedures: Evidence From a Hierarchical Bayesian Network Meta-Analysis of 124 Trials and 28 240 Patients. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.116.004383. [PMID: 28487354 DOI: 10.1161/circinterventions.116.004383] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 03/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effectiveness of currently available effective preventive strategies for contrast-induced acute kidney injury (CIAKI) is a matter of debate. METHODS AND RESULTS We performed a Bayesian random-effects network meta-analysis of 124 trials (28 240 patients) comparing a total of 10 strategies: saline, statin, N-acetylcysteine (NAC), sodium bicarbonate (NaHCO3), NAC+NaHCO3, ascorbic acid, xanthine, dopaminergic agent, peripheral ischemic preconditioning, and natriuretic peptide. Compared with saline, the risk of CIAKI was reduced by using statin (odds ratio [OR], 0.42; 95% credible interval [CrI], 0.26-0.67), xanthine (OR, 0.32; 95% CrI, 0.17-0.57), ischemic preconditioning (OR, 0.48; 95% CrI, 0.26-0.87), NAC+NaHCO3 (OR, 0.50; 95% CrI, 0.33-0.76), NAC (OR, 0.68; 95% CrI, 0.55-0.84), and NaHCO3 (OR, 0.66; 95% CrI, 0.47-0.90). The benefit of statin therapy was consistent across multiple sensitivity analyses, whereas the efficacy of all the other strategies was questioned by restricting the analysis to high-quality trials. Overall, high heterogeneity was observed for comparisons involving xanthine and ischemic preconditioning, although the impact of NAC and xanthine was probably influenced by publication bias/small-study effect. Hydration alone was the least effective preventive strategy for CIAKI. Meta-regressions did not reveal significant associations with baseline creatinine and contrast volume. In patients with diabetes mellitus, no strategy was found to reduce the incidence of CIAKI. CONCLUSIONS In patients undergoing percutaneous coronary procedures, statin administration is associated with a marked and consistent reduction in the risk of CIAKI compared with saline. Although xanthine, NAC, NaHCO3, NAC+NaHCO3, ischemic preconditioning, and natriuretic peptide may have nephroprotective effects, these results were not consistent across multiple sensitivity analyses.
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Affiliation(s)
- Daniele Giacoppo
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - Giuseppe Gargiulo
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - Sergio Buccheri
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - Patrizia Aruta
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - Robert A Byrne
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - Salvatore Cassese
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - George Dangas
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - Adnan Kastrati
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - Roxana Mehran
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - Corrado Tamburino
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.)
| | - Davide Capodanno
- From the Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Italy (D.G., G.G., S.B., C.T., D.C.); Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Germany (D.G., R.A.B., S.C., A.K.); Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy (G.G.); Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy (P.A.); Interventional Cardiology Clinical Trials and Research, Icahn School of Medicine, Mount Sinai, New York, NY (G.D., R.M.); and DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Germany (A.K.).
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Langabeer JR, Henry TD, Fowler R, Champagne-Langabeer T, Kim J, Jacobs AK. Sex-Based Differences in Discharge Disposition and Outcomes for ST-Segment Elevation Myocardial Infarction Patients Within a Regional Network. J Womens Health (Larchmt) 2018; 27:1001-1006. [PMID: 29319393 DOI: 10.1089/jwh.2017.6553] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND It is known that women with ST-segment elevation myocardial infarction (STEMI) have higher mortality in comparison to men. While the reasons for this sex-based difference are not completely understood, biologic differences and disparities in care have been implicated. Whether these differences persist within an urban, regional STEMI system of care with defined protocols is unclear. Our objective was to explore sex-related effects in outcomes in a large regional system of care. MATERIALS AND METHODS Data were drawn from a regional subset of the National Cardiovascular Data Registry for 33 hospitals in and around Dallas County, Texas from 2010 to 2015. We explored adjusted differences between women and men for discharge disposition, door to balloon (D2B), total ischemic time (TIS), length of stay, and in-hospital mortality rates. RESULTS Multivariate regressions to control for confounding factors, including age, D2B, and TIS, were significantly prolonged in women compared to men (D2B 58 vs. 54 minutes; TIS 206 vs. 178 minutes; both p < 0.001). Length of stay was 0.45 median days longer. Women were also much less likely to survive at discharge than men [odds ratio (OR): 0.63; 95% confidence interval (CI): 0.52-0.76]. Most notably, they were much less likely to be discharged to home than men (88% vs. 92%, p < 0.001). CONCLUSIONS In this study, we found that sex-based disparities persist for both cardiovascular outcomes and discharge disposition, even in a modern regionalized system of care.
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Affiliation(s)
- James R Langabeer
- 1 School of Biomedical Informatics, University of Texas Health Science Center , Houston, Texas
| | | | - Raymond Fowler
- 3 Department of Emergency Medicine, University of Texas Southwestern Medical Center , Dallas, Texas
| | | | - Junghyun Kim
- 1 School of Biomedical Informatics, University of Texas Health Science Center , Houston, Texas
| | - Alice K Jacobs
- 4 Department of Cardiology, Boston Medical Center, Boston University School of Medicine , Boston, Massachusetts
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Fordyce CB, Al-Khalidi HR, Jollis JG, Roettig ML, Gu J, Bagai A, Berger PB, Corbett CC, Dauerman HL, Fox K, Garvey JL, Henry TD, Rokos IC, Sherwood MW, Wilson BH, Granger CB. Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004061. [PMID: 28082714 DOI: 10.1161/circinterventions.116.004061] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 11/17/2016] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Christopher B Fordyce
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.).
| | - Hussein R Al-Khalidi
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - James G Jollis
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Mayme L Roettig
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Joan Gu
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Akshay Bagai
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Peter B Berger
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Claire C Corbett
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Harold L Dauerman
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Kathleen Fox
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - J Lee Garvey
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Timothy D Henry
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Ivan C Rokos
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Matthew W Sherwood
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - B Hadley Wilson
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
| | - Christopher B Granger
- From the Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.F., H.R.A.-K., M.L.R., J.G., K.F., M.W.S., C.B.G.); University of North Carolina, Chapel Hill (J.G.J.); St. Michael's Hospital, University of Toronto, ON, Canada (A.B.); Northwell Health, Great Neck, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart & Vascular Institute, Carolinas Medical Center, Charlotte, NC (B.H.W.)
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Kragholm K, Lu D, Chiswell K, Al-Khalidi HR, Roettig ML, Roe M, Jollis J, Granger CB. Improvement in Care and Outcomes for Emergency Medical Service-Transported Patients With ST-Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study. J Am Heart Assoc 2017; 6:e005717. [PMID: 29021273 PMCID: PMC5721828 DOI: 10.1161/jaha.117.005717] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 08/23/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) with out-of-hospital cardiac arrest (OHCA) may benefit from direct transport to a percutaneous cardiac intervention (PCI) hospital but have previously been less likely to bypass local non-PCI hospitals to go to a PCI center. METHODS AND RESULTS We reported time trends in emergency medical service transport and care of patients with STEMI with and without OHCA included from 171 PCI-capable hospitals in 16 US regions with participation in the Mission: Lifeline STEMI Accelerator program between July 1, 2012, and March 31, 2014. Time trends by quarter were assessed using logistic regression with generalized estimating equations to account for hospital clustering. Of 13 189 emergency medical service-transported patients, 88.7% (N=11 703; 10.5% OHCA) were taken directly to PCI hospitals. Among 1486 transfer-in patients, 21.7% had OHCA. Direct transport to a PCI center for OHCA increased from 74.7% (July 1, 2012) to 83.6% (March 31, 2014) (odds ratio per quarter, 1.07; 95% confidence interval, 1.02-1.14), versus 89.0% to 91.0% for patients without OHCA (odds ratio, 1.03; 95% confidence interval, 0.99-1.07; interaction P=0.23). The proportion with prehospital ECGs increased for patients taken directly to PCI centers (53.9%-61.9% for those with OHCA versus 73.9%-81.9% for those without OHCA; interaction P=0.12). Of 997 patients with OHCA taken directly to PCI hospitals and treated with primary PCI, first medical contact-to-device times within the guideline-recommended goal of ≤90 minutes were met for 34.5% on July 1, 2012, versus 41.8% on March 31, 2014 (51.6% and 56.1%, respectively, for 9352 counterparts without OHCA; interaction P=0.72). CONCLUSIONS Direct transport to PCI hospitals increased for patients with STEMI with and without OHCA during the 2012 to 2014 Mission: Lifeline STEMI Accelerator program. Proportions with prehospital ECGs and timely reperfusion increased for patients taken directly to PCI hospitals.
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Affiliation(s)
| | - Di Lu
- Duke Clinical Research Institute, Durham, NC
| | | | | | | | - Matthew Roe
- Duke Clinical Research Institute, Durham, NC
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Liang FW, Lee JC, Lu TH, Yin WH. Trends in proportions of hospitals and operators not meeting minimum percutaneous coronary intervention volume standards in Taiwan, 2001-2013. Catheter Cardiovasc Interv 2017; 92:247-250. [PMID: 28963782 DOI: 10.1002/ccd.27343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine trends in proportions of hospitals and operators not meeting the minimum percutaneous coronary intervention (PCI) volume standards in Taiwan during 2001-2013. BACKGROUND The 2013 Clinical Competence Statement recommends that operators perform a minimum of ≥50 PCIs annually (averaged over a 2-year period) in hospitals conducting ≥200 PCIs annually. METHODS Taiwan National Health Insurance claims data from 2001 to 2013 are used to determine the annual numbers of PCIs performed by each hospital and operator. RESULTS The percentage of hospitals conducting annual PCI volumes of <200 decreased from 57% (26/46) in 2001 to 39% (29/74) in 2007 and 33% (33/91) in 2013; the percentage of operators conducting PCI volumes <50 annually remained relatively constant at 60% (146/243) in 2001, 60% (270/452) in 2007, and 58% (354/611) in 2013; and the percentage of operators conducting low volumes (<50) in low-volume hospitals (<200) decreased from 24% (57/243) in 2001 to 15% (66/452) in 2007 and 12% (76/611) in 2013. CONCLUSIONS Approximately one-third of hospitals and three-fifths of operators in Taiwan failed to meet minimum PCI volume standards. Further research examining patient outcomes from PCIs performed by low-volume hospitals and operators is recommended.
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Affiliation(s)
- Fu-Weng Liang
- The NCKU Research Center for Health Data and Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jo-Chi Lee
- The NCKU Research Center for Health Data and Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsung-Hsueh Lu
- The NCKU Research Center for Health Data and Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Hsian Yin
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, and Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
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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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49
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Fordyce CB, Henry TD, Granger CB. Implementation of Regional ST-Segment Elevation Myocardial Infarction Systems of Care: Successes and Challenges. Interv Cardiol Clin 2017; 5:415-425. [PMID: 28581992 DOI: 10.1016/j.iccl.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Current guidelines recommend that communities create and maintain a regional system of ST-segment elevation myocardial infarction (STEMI) care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Availability and timely access is a challenge in many areas of the United States. This article reviews clinical trial data supporting the use of primary percutaneous coronary intervention as the optimal reperfusion strategy, and fibrinolysis as an option when this is not possible. It then describes the outcomes and benefits of implementing regional systems of STEMI care, and discusses ongoing challenges for STEMI system implementation, including inadequate data collection and feedback, and hospital and physician competition.
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Affiliation(s)
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, CA 90048, USA
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50
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Consuegra-Sánchez L, Jaulent-Huertas L, Vicente-Gilabert M, Díaz-Pastor Á, Escudero-García G, Alonso-Fernández N, Gil-Sánchez FJ, Martínez-Hernández J, Sanchis-Forés J, Galcerá-Tomás J, Melgarejo-Moreno A. Effect of part-time cardiac catheterization facilities in patients with acute myocardial infarction. Int J Cardiol 2017; 236:85-90. [PMID: 28274580 DOI: 10.1016/j.ijcard.2017.02.148] [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: 01/03/2017] [Revised: 02/23/2017] [Accepted: 02/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although the easy availability of invasive cardiac care facilities is associated with an increase in their use, their influence on outcomes is not clear. We sought to investigate whether a newly available cardiac catheterization laboratory (CCL) performing percutaneous coronary intervention (PCI) on a part-time (PT) basis might improve outcomes in patients with acute myocardial infarction (AMI). METHODS This was an observational cohort study that included all consecutive patients with AMI admitted to a secondary-level hospital in Spain before and after the PT-CCL opened in January 2006: during 1998-2005 and 2006-2014, respectively. All-cause in-hospital and long-term mortality were the co-primary endpoints. In-hospital complications and length of stay were secondary endpoints. For the analyses, patients were stratified according to propensity-score (PS) quintiles. RESULTS A total of 5339 patients were recruited, and 50.3% were managed after the opening of the PT-CCL. The PT-CCL was associated with greater use of PCI (81.2 vs. 32.5%, p<0.001) and guidelines-recommended medication (all p<0.001), lower risk of recurrent angina (PS-adjusted RR=0.160, 95% CI 0.115-0.222) and shorter length of hospital stay (PS-adjusted RR for length of stay <8days=0.357, 95% CI 0.301-0.422). In patients with NSTEMI, PT-CCL was associated with improved long-term survival (PS-adjusted HR=0.764, 95% CI 0.602-0.970). CONCLUSIONS In patients with AMI, a new PT-CCL was associated with greater use of PCI and guideline-recommended medication, lower risk of recurrent angina and shorter length of hospital stay. In a subset of patients with NSTEMI, PT-CCL was associated with improved long-term survival.
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Affiliation(s)
- Luciano Consuegra-Sánchez
- Cardiology Department and Acute Coronary Care Unit, Universidad Católica de Murcia-UCAM, Hospital Universitario Santa Lucía de Cartagena, Spain.
| | - Leticia Jaulent-Huertas
- Cardiology Department and Acute Coronary Care Unit, Universidad Católica de Murcia-UCAM, Hospital Universitario Santa Lucía de Cartagena, Spain
| | | | - Ángela Díaz-Pastor
- Cardiology Department and Acute Coronary Care Unit, Universidad Católica de Murcia-UCAM, Hospital Universitario Santa Lucía de Cartagena, Spain
| | - Germán Escudero-García
- Cardiology Department and Acute Coronary Care Unit, Universidad Católica de Murcia-UCAM, Hospital Universitario Santa Lucía de Cartagena, Spain
| | - Nuria Alonso-Fernández
- Cardiology Department and Acute Coronary Care Unit, Universidad Católica de Murcia-UCAM, Hospital Universitario Santa Lucía de Cartagena, Spain
| | - Francisco Javier Gil-Sánchez
- Cardiology Department and Acute Coronary Care Unit, Universidad Católica de Murcia-UCAM, Hospital Universitario Santa Lucía de Cartagena, Spain
| | - Juan Martínez-Hernández
- Cardiology Department and Acute Coronary Care Unit, Universidad Católica de Murcia-UCAM, Hospital Universitario Santa Lucía de Cartagena, Spain
| | - Juan Sanchis-Forés
- Cardiology Department, University Clinic Hospital, INCLIVA, Department of Medicine, University of Valencia, CIBER-CV, Valencia, Spain
| | - José Galcerá-Tomás
- Acute Coronary Care Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Antonio Melgarejo-Moreno
- Cardiology Department and Acute Coronary Care Unit, Universidad Católica de Murcia-UCAM, Hospital Universitario Santa Lucía de Cartagena, Spain
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