Rapid early action for coronary treatment - REACT

Description:

The REACT Trial was a randomized prospective study designed to assess whether a program of community intervention would improve AMI treatment by reducing patient delay to access the health care system.

Hypothesis:

A program of community intervention targeting mass media, community organizations, and professional, public and patient education would reduce patient delay from symptom onset of AMI to hospital presentation and would increase emergence medical service (EMS) use.

Study Design

Study Design:

Patients Screened: 59,944
Patients Enrolled: 20,364
Mean Patient Age: 30 years or older

Patient Populations:

All adults who presented to a hospital ED with a chief complaint of chest pain of suspected coronary origin and were discharged with a coronary heart disease-related diagnosis were included.

Exclusions:

Institutionalized individuals, those transferred from hospitals outside of the study areas, and those presenting with other causes of chest pain were not included.

Primary Endpoints:

Time from symptom onset to ED arrival and EMS use.

Secondary Endpoints:

Public awareness and knowledge of program messages, intensity of the intervention.

Drug/Procedures Used:

The REACT study was conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states. One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10563). The other city in each pair was randomly assigned to reference status (primary population, n=9,801).

Concomitant Medications:

N/A

Principal Findings:

General population surveys showed increased public awareness of program messages. Patient delay from symptom onset to hospital arrival at baseline (median 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% CI -8.6 to -0.6), but it did not differ significantly from that observed in reference communities (-6.8% per year; 95% CI, -14.5% to 1.6%, p=0.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7% to 34%, p<0.05). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly.

Interpretation:

In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be further decreased in patients with suspected AMI. Several explanations might account for the apparent lack of efficacy of the intervention in the REACT trial. The lack of effect may represent a failure of the intervention to achieve its goal under the conditions of the REACT design. The educational messages may have been flawed, lacked sufficient intensity, duration, or both, or were targeted to the wrong groups. Another explanation may be found in the relatively short median delay times observed at baseline and throughout the study. The increased use of the EMS systems may have added to the delay times in the intervention communities.

References:

Russell V. Luepker, M.D., James M. Raczynski, Ph.D., Stravoula Osganian, M.D., Ph.D., Robert J. Goldberg, Ph.D., John R. Finnegan, Jr, Ph.D., Jerris R. Hedges, M.D., David C. Goff, Jr, M.D., Ph.D., Mickey S. Eisenberg, M.D., Ph.D., Jane G. Zapka, Sc.D., Henry A. Feldman, Ph.D., Darwin R. Labarthe, M.D., Ph.D., Paul G. McGovern, Ph.D., Carol E. Cornell, Ph.D., Michael A. Proschan, Ph.D., and Denise G. Simons-Morton, M.D., Ph.D. For the REACT Study Group. “Effect of a Community Intervention on Patient Delay and Emergency Medical Service Use in Acute Coronary Heart Disease. The Rapid Early Action for Coronary Treatment (REACT) trial”. JAMA 2000; 284:60-67

Clinical Topics: Atherosclerotic Disease (CAD/PAD)

Keywords: Coronary Artery Disease, Chest Pain, Mass Media


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