1. The adjusted in-hospital mortality rate was lower for patients who received treatment within the range of target times versus those who did not.
2. System-wide targets for time-to-treatment are largely not met, with the greatest time delays caused by patient transfers between hospitals.
Level of Evidence Rating: 2 (Good)
Study Rundown: Efficient access to coronary reperfusion therapy is the greatest predictor of mortality outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI). The logistics of care, including travel with emergency services, transfers between and within a hospital, and setup of a catheterization lab, are measures of successful STEMI management and strongly influence associated morbidity and mortality. This study summarized trends in processes of care and corresponding in-hospital mortality rates for patients with STEMI in the United States.
In total, 114 871 patients were included from 601 participating hospitals, of which 496 hospitals were designated for percutaneous coronary intervention (PCI) centers. Ground transport via emergency services was the most common mode of arrival to hospital; overall, 20% of patients had a hospital-specified reason for delayed arrival (i.e., need for intubation, cardiac arrest). The time to first contact with a medical professional was reduced in patients who were transferred by emergency services compared to those who walked into PCI centers, and the time delays were increased over the study period. Patients in PCI centers who waited less than 20 minutes between first medical contact and activation of the catheterization lab were significantly less likely to die in hospital.
The present study by Jollis et al. summarizes trends in the provision of care for patients presenting with STEMI in the United States in recent years. It reinforces the importance of meeting system targets of time to care, as these parameters are significantly associated with reductions in in-hospital mortality. This work is important in defining areas of improvement on a broad scale and lends itself to further studies identifying specific barriers to care which can be overcome. These findings are strengthened by the large sample size of this study. A major limitation of this work is that the registry data is limited and include mostly self-reported measures which have not been audited.
Click here to read this study in JAMA
Click to read an accompanying editorial in JAMA
Relevant reading: Evaluation of STEMI regionalization on access, treatment, and outcomes amongst adults living in nonminority and minority communities
In-Depth [cross-sectional study]: Data from consecutive, eligible patients receiving care at select institutions were considered. Patients were eligible for inclusion if they had evidence of STEMI or STEMI equivalent (isolated posterior MI or new left bundle branch block) between 2018 and 2021. The primary objective of global STEMI treatment in the United States is to provide reperfusion to 75% of patients within 90 minutes of first medical contact for patients presenting to hospitals capable of PCI and 120 minutes for patients presenting to other centers & requiring interhospital transfer.
Among patients presenting to a PCI center, the majority (63%) arrived via emergency services; amongst those transferred between hospitals, ground transportation (70%) was the most common. The need for intubation/cardiac arrest was the most common factor causing delays (6.3%); overall, 20% of patients experienced hospital-specified delays to transport. The median time from symptom onset to first contact with a health professional was 52 minutes in patients who were transferred by emergency services versus 118 minutes for those who walked into a PCI-capable center.
The adjusted odds ratio for in-hospital mortality in patients who waited for less versus more than 20 minutes between first medical contact and activation of the catheterization lab in a PCI center was 0.54 (95% confidence interval 0.48-0.60). Amongst patients presenting initially to a non-PCI center, the target of 120 minutes from initial presentation to arrival in a catheterization lab was associated with a significant reduction in mortality of 4.3% from 14.2% in those not achieving this target. The adjusted odds ratio was 0.44 (95% confidence interval 0.26-0.71).
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