Early Experience of Busan-Ulsan Regional Cardiocerebrovascular Center Project in the Treatment of ST Elevation Myocardial Infarction

Mortality and Disparities of Acute Myocardial Infarction and Stroke in Korea, 2008-2019

PURPOSE

Acute myocardial infarction (AMI) and stroke are leading global causes of death and can be used to assess acute care quality. We examined the 30-day mortality trends after emergency department admission for AMI and stroke in Korea from 2008 to 2019, focusing on regional and income disparities.

MATERIALS AND METHODS

The AMI and stroke patients admitted to hospitals in Korea were collected from the claims data. We analyzed age and sex-standardized 30-day mortality for AMI, as well as hemorrhagic and ischemic strokes. Disparities in mortality were analyzed using absolute differences and relative ratios between the Organization for Economic Cooperation Development (OECD) and Korea, and among income levels and regions in Korea. A 12-year joinpoint regression was used to determine the annual percent change and the average annual percent change.

RESULTS

The trends in the 30-day AMI mortality of Korea were not significantly changed from 2008 to 2019; the gap remained at 1.2 between the OECD and Korea. Korea maintained lower mortality rates for hemorrhagic and ischemic stroke than the mean of OECD. In Korea, the 30-day hemorrhagic stroke mortality showed a constant decreasing trend for the higher-income group living in urban areas; it led to a widened gap based on income levels in urban areas. The 30-day mortality for ischemic stroke tended to decrease in the higher-income group and urban areas.

CONCLUSION

National-level intervention is needed to manage regional and income-based disparities in AMI and stroke 30-day mortality. It is important to understand the variance in mortality rate by different geographical regions and income levels to establish an appropriate public health strategy.

The Busan Regional CardioCerebroVascular Center Project��s Experience Over a Decade in the Treatment of ST-segment Elevation Myocardial Infarction

Objectives

The Regional CardioCerebroVascular Center (RCCVC) project was initiated to improve clinical outcomes for patients with acute myocardial infarction or stroke in non-capital areas of Korea. The purpose of this study was to evaluate the outcomes and issues identified by the Busan RCCVC project in the treatment of ST-segment elevation myocardial infarction (STEMI).

Methods

Among the patients who were registered in the Korean Registry of Acute Myocardial Infarction for the RCCVC project between 2007 and 2019, those who underwent percutaneous coronary intervention (PCI) for STEMI at the Busan RCCVC were selected, and their medical data were compared with a historical cohort.

Results

In total, 1161 patients were selected for the analysis. Ten years after the implementation of the Busan RCCVC project, the median door-to-balloon time was reduced from 86 (interquartile range [IQR], 64–116) to 54 (IQR, 44–61) minutes, and the median symptom-to-balloon time was reduced from 256 (IQR, 180–407) to 189 (IQR, 118–305) minutes (p<0.001). Inversely, the false-positive PCI team activation rate increased from 0.6% to 21.4% (p<0.001). However, the 1-year cardiovascular death and major adverse cardiac event rates did not change. Even after 10 years, approximately 75% of the patients had a symptom-to-balloon time over 120 minutes, and approximately 50% of the patients underwent inter-hospital transfer for primary PCI.

Conclusions

A decade after the implementation of the Busan RCCVC project, although time parameters for early reperfusion therapy for STEMI improved, at the cost of an increased false-positive PCI team activation rate, survival outcomes were unchanged.

Effect of percutaneous coronary intervention team prenotification based on real time electrocardiogram transmission in interhospital transfer of ST elevation myocardial infarction patients: pilot trial of Preparing Revascularization Effort before Patients' Arrival via Regionalization Engagement protocol

Objective

Prompt reperfusion is important for patients with ST elevation myocardial infarction (STEMI). However, patients often require interhospital transfer for percutaneous coronary intervention (PCI) because not all hospitals can provide. The purpose of this study is to reduce the PCI delay using a regionalization protocol in patients with STEMI following transfer from another hospital lacking PCI facility.

Methods

We established a revascularization protocol designated as Preparing Revascularization Effort before Patients’ Arrival via Regionalization Engagement (PREPARE) for the STEMI patients transferred from an outside regional hospital. The protocol included immediate referral acceptance by an emergency physician, real-time electrocardiogram sharing via mobile phone and early activation of the PCI team. We analyzed the differences between the PREPARE and the non-PREPARE groups.

Results

In the PREPARE group, the median time from the first hospital visit to the ballooning procedure via PCI at the receiving facility (D1-to-B time) was 111.0 (interquartile range 97.0– 130.0) minutes, which was significantly shorter than in the non-PREPARE group 134.0 (interquartile range 115.0–182.0) minutes. The proportion of D1-to-B time within 120 minutes was 30.4% in the group and 60.0% in the PREPARE group, which represents a significant difference (P=0.004). Multivariate logistic regression analysis revealed that patient transfer via PREPARE protocol (odds ratio, 3.399; 95% confidence interval, 1.150–10.050, P=0.027) was related to adequate D1-to-B time. No statistically significant differences were found in the hospital length of stay or major adverse cardiac events within 4 weeks.

Conclusion

The PREPARE protocol is an effective strategy to reduce the time to revascularization of the transferred STEMI patients.

Impact of Regional Cardiocerebrovascular Centers on Myocardial Infarction Patients in Korea: A Fixed-effects Model

Objectives

The Regional Cardiocerebrovascular Center (RCCVC) Project designated local teaching hospitals as RCCVCs, in order to improve patient outcomes of acute cardiocerebrovascular emergencies by founding a regional system that can adequately transfer and manage patients within 3 hours. We investigated the effects of RCCVC establishment on treatment volume and 30-day mortality.

Methods

We constructed a panel dataset by extracting all acute myocardial infarction cases that occurred from 2007 to 2016 from the Health Insurance Review and Assessment Service claims data, a national and representative source. We then used a panel fixed-effect model to estimate the impacts of RCCVC establishment on patient outcomes.

Results

We found that the number of cases of acute myocardial infarction that were treated increased chronologically, but when the time effect and other related covariates were controlled for, RCCVCs only significantly increased the number of treatment cases of female in large catchment areas. There was no statistically significant impact on 30-day mortality.

Conclusions

The establishment of RCCVCs increased the number of treatment cases of female, without increasing the mortality rate. Therefore, the RCCVCs might have prevented potential untreated deaths by increasing the preparedness and capacity of hospitals to treat acute myocardial infarction patients.

Treatment of acute myocardial infarction in the sub-arctic region of Norway. Do we offer an equal quality of care?

Patients, relatives, healthcare workers and administrators are concerned about the quality of care offered. We aimed to explore the treatment of acute myocatrdial infarction (AMI) in Northern Norway, compare it with the national figures, and document whether there is an equal quality of care or not. The retrospective study included data on patients' treatment for AMI. The following sources were employed. The Norwegian Patient Registry, National Quality of Care Database, Norwegian Myocardial Infarction Registry and data from the National Air Ambulance Services of Norway. The period 2012-2014/15 was studied and the variables were: incidence of AMI, gender and age adjusted rates of AMI and revascularization (PCI, CABG) based on patient's place of living (according to hospital catchment area) and 30-day survival rate. The annual incidence of AMI was 9% higher in the northern region. Significant incidence variations (2.7–5.9 AMI/1000 inhabitants) between the hospitals' catchment areas were revealed. The 30-day survival rate varied between 85.1–92.1% between hospitals. The variation in revascularization/AMI rate was 0.72–1.54. Air amublance services' availability varied through the day. In conclusion, significant variations in the AMI rate and an unequal service within the region was revealed.

The first-door-to-balloon time delay in STEMI patients undergoing interhospital transfer

BACKGROUND

Interhospital transfer delays for ST-elevation myocardial infarction (STEMI) patients requiring primary percutaneous coronary intervention (PCI) may be shortened by improved regional care systems. We evaluated the transfer process and first door-to-balloon (D1toB) time in STEMI patients who underwent interhospital transfer for primary PCI.

METHODS AND RESULTS

We evaluated the D1toB time in 1837 patients who underwent interhospital transfer for primary PCI from the Cardiovascular Disease Surveillance program in Korea. Only 29.3% of patients had a D1toB time less than 120 minutes, as recommended by the American College of Cardiology Foundation/American Heart Association guidelines for the management of STEMI. After adjusting for potential confounders, chest pain at presentation (adjusted odds ratio [AOR], 2.06; 95% confidence interval [CI], 1.18-3.83), transfer to a PCI center with an annual PCI volume greater than 200 (AOR, 1.35; 95% CI, 1.04-1.74), and higher urbanization level (AOR, 2.01 [95% CI, 1.40-2.91], for urban areas; AOR, 3.70 [95% CI, 2.59-3.83], for metropolitan areas) showed beneficial effects on reducing the D1toB time. The median length of stay in the referring hospital (D1LOS) and interhospital transport time were 50 (interquartile range [IQR], 30-100) minutes and 32 (IQR, 20-51) minutes, respectively. The median time interval from the door of the receiving hospital to balloon insertion was 55 (IQR, 40-79) minutes.

CONCLUSIONS

Patients with STEMI undergoing interhospital transfer did not receive definite care within the recommended therapeutic time window. Delays in the transfer process (length of stay in the referring hospital and interhospital transport time) were major contributors to the delay in the D1toB time.

The burden of acute myocardial infarction after a regional cardiovascular center project in Korea

OBJECTIVE

The aim of this study was to examine the impact of a government-directed regional cardiovascular center (RCVC) project on the length of stay (LOS) and medical costs due to acute myocardial infarction (AMI).

DESIGN

A retrospective claim data review.

SETTING

Forty hospitals including four RCVCs in Korea.

PARTICIPANTS

A total of 1469 AMI patients who visited a RCVC in two regions between February 2009 and December 2011.

INTERVENTIONS

RCVC project has been fostering specialized center by region for management of cardiovascular disease. It has built a system that could receive intensive care quickly within 3 h when disease occurred.

MAIN OUTCOME MEASURES

Changes in the LOS and cost were evaluated using the difference-in-differences (DIDs) method combined with propensity score matching (1:1) and multilevel analysis with adjustment for patient's and institutional factors.

RESULTS

The net effect of RCVC project implementation showed decline of LOS (-0.71 days) and total medical costs (-797 US dollars) by DID. After the RCVC project, the LOS for patients with AMI hospitalized in a RCVC was decreased by 8.9% (β = -0.094, P = 0.041) compared with patients hospitalized in a hospital not designed as a RCVC. Compared with costs before the RCVC project, they were decreased by 11.5% (β = -0.122, P = 0.004).

CONCLUSIONS

We provided evidence regarding the change in the societal burden due to AMI after regionalization. Although there was a reduction of LOS and direct medical costs reported in limited number of regionalized hospitals, in the long term we can anticipate an expanding impact in all regionalized hospitals.

Regional differences in treatment frequency and case-fatality rates in korean patients with acute myocardial infarction using the Korea national health insurance claims database: findings of a large retrospective cohort study

Issues regarding healthcare disparity continue to increase in connection with access to quality care for acute myocardial infarction (AMI), even though the case-fatality rate (CFR) continues to decrease. We explored regional variation in AMI CFRs and examined whether the variation was due to disparities in access to quality medical services for AMI patients. A dataset was constructed from the Korea National Health Insurance Claims Database to conduct a retrospective cohort study of 95,616 patients who were admitted to a hospital in Korea from 2003 to 2007 with AMI. Each patient was followed in the claims database for information about treatment after admission or death. The procedure rate decreased as the region went "down" from Seoul to the county level, whereas the AMI CFR increased as the county level as a function of proximity to the county level (30-day AMI CFRs: Seoul, 16.4%; metropolitan areas, 16.2%, cities; 18.8%, counties, 39.4%). Even after adjusting for covariates, an identical regional variation in the odds of patients receiving treatment services and dying was identified. After adjusting for invasive and medical management variables in addition to earlier covariates, the death risk in the counties remained statistically significantly higher than in Seoul; however, the degree of the difference decreased greatly and the significant differences in metropolitan areas and cities disappeared. Policy interventions are needed to increase access to quality AMI care in county-level local areas because regional differences in the AMI CFR are likely caused by differences in the performance of medical and invasive management among the regions of Korea. Additionally, a public education program to increase the awareness of early symptoms and the necessity of visiting the hospital early should be established as the first priority to improve the outcome of AMI patents, especially in county-level local areas.