Lower long-term mortality within a regional system of care for ST-elevation myocardial infarction

Impact of telemedicine interventions on mortality in patients with acute myocardial infarction: a systematic review and meta-analysis

BACKGROUND

Despite the promise of telemedicine to improve care for ischaemic heart disease, there are significant obstacles to implementation. Demonstrating improvement in patient-centred outcomes is important to support development of these innovative strategies.

OBJECTIVE

To assess the impact of telemedicine interventions on mortality after acute myocardial infarction (AMI).

METHODS

Articles were searched in MEDLINE, Cochrane Central Register of Controlled Trials, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Base de Dados de Enfermagem (BDENF), Indice Bibliográfico Español en Ciencias de la Salud (IBECs), Web of Science, Scopus and Google Scholar, from January 2004 to January 2018. Study selection and data extraction were performed by two independent reviewers. In-hospital mortality (primary outcome), and door-to-balloon (DTB) time, 30-day mortality and long-term mortality (secondary outcomes) were assessed. Random effects models were applied to estimate pooled results.

RESULTS

Thirty non-randomised controlled and seven quasi-experimental studies were included (16 960 patients). They were classified as moderate or serious risk of bias by ROBINS-I (Risk Of Bias In Non-randomized Studies-of Interventions tool). In 31 studies, the intervention was prehospital ECG transmission. Telemedicine was associated with reduced in-hospital mortality compared with usual care (relative risk (RR) 0.63(95% confidence interval[CI] 0.55 to 0.72); I² <0.001%). DTB time was consistently reduced (mean difference -28 (95% CI -35 to -20) min), but showed large heterogeneity (I²=94%). Thirty-day mortality (RR 0.62;95% CI 0.43 to 0.85) and long-term mortality (RR 0.61(95% CI 0.40 to 0.92)) were also reduced, with moderate heterogeneity (I²=52%).

CONCLUSIONS

There is moderate-quality evidence that telemedicine strategies, in particular ECG transmission, combined with the usual care for AMI are associated with reduced in-hospital mortality and very-low quality evidence that they reduce DTB time, 30-day mortality and long-term mortality.

Temporal associations of early patient transfers and mortality with the implementation of a regional myocardial infarction care model

BACKGROUND

In order to reduce the delays encountered through patient transfer, regional care models have been developed that directly transport subsets of acute myocardial infarction (AMI) patients to hospitals with percutaneous coronary intervention (PCI) facilities. Calgary is a Canadian city that implemented this type of model in 2004.

METHODS

The study population included 9768 AMI patients admitted to Calgary hospitals between 1997 and 2007. Administrative data were used to define patients who were directly admitted to the PCI hospital and those transferred there after initial admission to a hospital without specialized cardiac care. The differences in clinical characteristics and mortality trends of patients grouped by hospital delivery site and transfer practice are described.

RESULTS

The proportion of patients directly admitted to a PCI hospital has increased with the implementation of a regional care model. Among patients admitted to non-PCI facilities, the patients who are transferred are younger, more likely to be male, have a shorter length of stay, and have lower proportions of several comorbid conditions. The risk-adjusted in-hospital mortality odds ratio for patients who received care at the PCI hospital postmodel relative to those treated at non-PCI hospitals premodel was 0.38 (95% confidence interval, 0.31-0.47). The corresponding adjusted odds ratio was 0.60 (0.47-0.76).

CONCLUSIONS

Our results suggest changing care over time and trends toward improved outcomes. Patients' clinical characteristics appear to play a major role in the decision to transfer. Avoidance of the risk treatment paradox through refinement of regional transfer protocols ought to be a priority.

Geographic variations in percutaneous coronary interventions and coronary artery bypass graft surgery among Tennessee elders

OBJECTIVES

Coronary heart disease often presents with ST segment elevation acute myocardial infarction (STEMI). The American College of Cardiology/American Heart Association guidelines stress prompt reperfusion for STEMI. Examining geographic variations in treatment with PPCI (percutaneous primary coronary intervention) and CABG (coronary artery bypass graft) among metropolitan, micropolitan and non-micropolitan rural residents provides a descriptive basis for generating hypotheses concerning place and receipt of guidelines-based treatment.

METHODS

Using ICD-9 codes for STEMI and excluding beneficiaries with pre-existing MI in claims data, yielded a subset of 18,775 Tennessee Medicare beneficiaries experiencing STEMI from 1996 to 2002. The outcome variable is type of treatment, i.e., in accord (PPCI or CABG present) or not in accord (PPCI or CABG absent) with guidelines. Independent variables include type county residence, hospital volume, race, gender, and age. Analyses include cross-tabulation and logistic regression, estimating separate models by age and type of MI.

RESULTS

Micropolitan residents with STEMI have the lowest rates for PPCI (18.8%) versus 28.1% percent for metropolitan and 24.2% for non-micropolitan rural residents. CABG follows similar patterns at lower overall rates. Treatment at a heart center with high volume PPCI mediated the relationship between the likelihood of PPCI and place.

CONCLUSION

The correspondence between metropolitan and rural utilization suggests that access to a full range of treatment options and likelihood of "best practice" care is not dependent on metropolitan residence. This presents the possibility that with some policy changes, e.g., centralization of emergency heart care, the same may ultimately be true for micropolitan residents.