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Regional Systems of Care Demonstration Project
Study Questions:
What is the impact of organizing leadership, data collection, common protocols, and ongoing data review with timely feedback, on the percentage of patients receiving primary percutaneous coronary intervention (PCI) within guideline goals?
Methods:
The investigators established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1,253 emergency medical services (EMS) agencies in 16 regions across the United States. The prespecified primary outcome was the change in the percentage of patients meeting guideline goals for 6 quarters (post-baseline quarter). Patient characteristics and process measures were compared by use of the Wilcoxon rank sum test for two-group comparisons (the Kruskal-Wallis test for comparisons of >2 groups) for continuous variables and the Pearson χ2 or Fisher exact test, as appropriate, for categorical variables. The Cochran-Armitage test for trend was used to assess changes in rates over time.
Results:
Between July 2012 and December 2013, 23,809 patients presented with acute ST-segment elevation myocardial infarction (STEMI) (direct to PCI hospital: 11,765 EMS transported and 6,502 self-transported; 5,542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 vs. 114 minutes), incidence of cardiac arrest (10% vs. 3%), shock on admission (11% vs. 3%), and in-hospital mortality (8% vs. 3%; p < 0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50-55%; p < 0.001) and transferred patients (44-48%; p = 0.002). Despite regional variability, the greatest gains occurred among patients in the five most improved regions, increasing from 45-57% (direct EMS; p < 0.001) and 38-50% (transfers; p < 0.001).
Conclusions:
The authors concluded that by focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, they were able to increase significantly the proportion of patients treated within guideline goals.
Perspective:
This Mission: Lifeline STEMI Systems Accelerator Regional Systems of Care Demonstration Project represents the largest effort to date in the United States to organize treatment for STEMI on a regional basis, involving 484 hospitals, 1,253 EMS agencies, and many thousands of health care professionals. By focusing on first medical contact-to-device time, regional consensus treatment protocols, and common data collection, there was a significant increase in the proportion of patients treated within guideline goals. Furthermore, with the fullest implementation of the intervention, there were trends toward lower in-hospital mortality compared with national data toward the end of the measurement period. Overall, these data support continued efforts to implement regional STEMI networks to optimize STEMI care.
Keywords: Acute Coronary Syndrome, American Heart Association, Clinical Protocols, Emergency Medical Services, Heart Arrest, Hospital Mortality, Leadership, Myocardial Infarction, Percutaneous Coronary Intervention, Process Assessment, Health Care
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