A System of Care for Indian Patients With STEMI

Study Questions:

What is the access to reperfusion and percutaneous coronary intervention (PCI) during ST-segment elevation myocardial infarction (STEMI) using a hub-and-spoke model?

Methods:

This was a multicenter, prospective, observational study of a quality improvement program among 2,420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the four clusters before implementation of the program (preimplementation data). The investigators required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the four clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period. An integrated, regional quality improvement program that linked the 35 spoke health care centers to the four large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology was assessed. Primary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality.

Results:

A total of 2,420 patients with STEMI (2,034 men [84.0%] and 386 women [16.0%]; mean [standard deviation] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1,522 in the postimplementation phase) were enrolled, with 1,053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs. 1,372 [90.1%]; p = 0.21). Coronary angiography (314 [35.0%] vs. 925 [60.8%]; p < 0.001) and PCI (265 [29.5%] vs. 707 [46.5%]; p < 0.001) were performed more often during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs. 85 [5.6%]; p = 0.83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs. 179 [14.2%]; p = 0.04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% confidence interval, 0.58-0.98; p = 0.04).

Conclusions:

The authors concluded that a hub-and-spoke model in South India improved STEMI care through greater use of PCI, and may improve 1-year mortality.

Perspective:

This study reports that a hub-and-spoke model in South India led to greater use of primary PCI and the pharmacoinvasive approach with stable reperfusion rates and times to treatment. Overall the hub-and-spoke model of a STEMI system of care connects peripherally located spoke health care centers with large PCI hub hospitals and appears to be a feasible and effective model for STEMI reperfusion in low- to middle-income countries. Additional studies are indicated to assess whether this model can be successfully implemented in other regions of India and elsewhere, and whether this translates into meaningful reductions in mortality and other hard endpoints. In addition to focusing on acute care, such as primary PCI, there also needs to be emphasis on long-term evidence-based primary and secondary prevention for patients with coronary artery disease.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Blood Pressure, Coronary Angiography, Emergency Medical Services, Fibrinolysis, Hospital Mortality, Insurance, Health, Medical Informatics, Myocardial Infarction, Percutaneous Coronary Intervention, Primary Health Care, Primary Prevention, Quality Improvement, Reperfusion


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