To improve emergency care for heart attack patients, new research suggests that expanding percutaneous coronary intervention (PCI) capacity at hospitals is less effective than using emergency medical services (EMS) to transport patients directly to existing PCI centers. Outcomes are most improved and costs are lowest when patients with the most deadly type of heart attack are transported by EMS directly to hospitals that offer PCI to open their blocked arteries, according to a computer-simulated study reported in Circulation: Cardiovascular Quality and Outcomes, a journal of the American Heart Association.

ST-segment elevation myocardial infarction (STEMI) is a severe heart attack caused by a complete blockage of a coronary artery. Studies have shown using PCI to unblock a clogged artery saves more lives and leads to fewer complications than using fibrinolytic therapy (injecting a clot-busting drug to dissolve the blockage). However, PCI can only be performed in a specialized hospital lab and only about one in four U.S. hospitals have one.

"Expanding patient access to PCI is critical to improving outcomes after heart attack and there are a range of approaches to accomplish this," said Thomas W. Concannon, Ph.D., the study's lead author and assistant professor at the Institute for Clinical Research and Health Policy Studies of Tufts Medical Center in Boston, Mass. "Our study is the first to compare an EMS strategy of ambulance diversion to a number of hospital-based PCI expansion strategies."

Using computer models to compare the strategies in 2,000 simulated cases of STEMI patients in Dallas County, Texas, the researchers found an ambulance diversion strategy was more than twice as effective and nearly 20 times less costly than any strategy involving expansion of PCI capacity at hospitals.

"Cost-wise, we looked at this from a societal perspective - the amount of money being spent on this care, regardless of who spends it," Concannon said. "The study suggests it would cost significantly more money to build and staff new PCI capacity than it would to divert to currently operating PCI labs."

With EMS diversion, patients are taken by ambulance directly to the closest hospital that offers PCI, even if it means bypassing closer hospitals that don't offer PCI. Hospital strategies include new construction and staffing of PCI labs and increased staffing and longer hours of operation for existing labs.

The study results strongly favor the use of EMS diversion strategies, which are already in place in some areas of the United States, Concannon said. Construction and staffing of new PCI-capacity at hospitals may not be warranted if an EMS strategy is available and feasible.

These data add to the existing evidence and support implementation strategies of the American Heart Association's Mission: Lifeline, an initiative to develop regional systems of care to ensure timely access to treatment for STEMI patients, said Alice K. Jacobs, M.D., immediate-past chair of the initiative.

"Community collaboration is essential to evaluate and build the appropriate EMS and hospital infrastructure at the local, regional and state level," said Jacobs, professor of medicine at Boston University School of Medicine and director of Cardiac Catheterization Laboratories and Interventional Cardiology at Boston Medical Center. "Mission: Lifeline is removing barriers to patient access through local implementation of national recommendations. Issues being considered include community legislation, regulation, geography, resources, training and funding. The results of this timely study suggest that in certain communities point of entry diversion protocols for STEMI patients will be more effective and less costly."

Co-authors are: David M. Kent, M.D.; Sharon-Lise Normand, Ph.D.; Joseph P. Newhouse, Ph.D.; John L. Griffith, Ph.D.; Joshua Cohen, Ph.D.; Joni R. Beshanksy, R.N., M.P.H.; John B.Wong, M.D.; Thomas Aversano, M.D.; and Harry P. Selker, M.D., M.S.P.H. Individual author disclosures and funding sources are in the manuscript.

Source:
American Heart Association