Regional STEMI Care Systems Improve Treatment Times

CHICAGO, IL—Implementing a regional system of care for patients with ST-segment elevation myocardial infarction (STEMI) is vital to increasing the number of patients reperfused within guideline goal times, according to results of an analysis of the Mission Lifeline STEMI ACCELERATOR program presented November 19, 2014, at the American Heart Association (AHA) Scientific Sessions.

In collaboration with the AHA, Matthew W. Sherwood, MD, MHS, of Duke University School of Medicine (Durham, NC), and colleagues worked with 16 large metropolitan regions in the United States—including 169 PCI hospitals, 214 non-PCI hospitals, and 1,253 EMS agencies—to organize and execute a standardized STEMI care protocol that would decrease treatment delays and increase guideline adherence. All PCI hospitals were required to participate in a common database, organize local regional leadership, and establish protocols for EMS activation and inter-hospital transfer. Ongoing measurement and feedback was provided through Mission: Lifeline regional quarterly reports containing blinded hospital comparisons. A standard operations manual was also distributed to assist regions with developing optimal individualized protocols.

Individual Improvements in Guideline Adherence as High as 12%

From October 2012 to March 2014, 23,809 STEMI patients within 12 hours of symptom onset were treated through the program—76.7% presented directly to a PCI center while the rest were transferred from another hospital. Mean patient age was 60 years and 30% were women.

Most patients (90%) were treated with PCI, and only 6% of eligible patients went untreated.  Notably, symptom duration prior to first medical contact was 69 minutes overall (89 minutes for transfer patients), but was lowest at 47 minutes for patients who arrived at a PCI center via EMS vs nearly 2 hours for those who arrived via their own transportation. Dr. Sherwood likened this difference to the fact that patients having more complicated STEMIs would likely not drive themselves to the hospital.

Overall rate of stroke was 0.8%, and shock (8%) and death (6%) were also relatively low.

Using the 75th percentile time for each region, the researchers found that while all regions reported door-to-device times that would have met previously defined national goals, very few of the regions met current goals for first-medical-contact-to-device time. “This further emphasizes the need for improvement,” Dr. Sherwood observed.

In a proof-of-concept, multivariable model of patients presenting directly via EMS, those who spent 30 minutes or less in the ED had lower mortality than patients who spent longer time there (P < .001).

The proportion of STEMI patients across all regions treated within guideline goal times—specifically among direct presenting patients (P = .025), those transported by EMS (P = .0048), and patients requiring hospital transfer (P = .007)—showed a modest increase in the percent of patients treated within guideline goal measures from the third quarter of 2012 through the first quarter of 2014.

Though the overall cohort showed only modest improvement in guideline adherence, there was substantial variation among regions. Among the 5 top-performing regions, there was as much as a 12% increase in the proportion of patients meeting guideline goals. The investigators also observed numerical improvement in survival in patients included in this study compared to national rates.

Good News in NYC

Among the limitations of the study were that the majority of the study time “was spent establishing leadership and recruiting centers into the NCDR ACTION registry,” according to Dr. Sherwood. Also, since many regions did not perform these process improvements until the end of the study period, he said, the full effects of the program may not be recognized yet. Finally, the observational nature of the study has inherent limitations, “thus the improvement may not be solely related to the intervention,” he added.

Considering the “giant size” of the United States, session co-moderator Harold L. Dauerman, MD, of the University of Vermont (Burlington, VT), a co-author of the study, asked which regions benefit most from the Mission: Lifeline program—those furthest away from 75^th percentile and with the most to gain, or those closest to optimal guideline adherence that “needed a small nudge.”

Dr. Sherwood said it is a mix of both. “It’s not as much about the difference between where they started, but the difference between the steps they were able to implement and goals that they were able to work on,” he said.

Panelist Roxana Mehran, MD, of Mount Sinai Medical Center (New York, NY), reported dramatic changes in her hospital’s guideline adherence after enrolling in Mission: Lifeline. “We were so focused on door-to-balloon time,” she said, adding that this program also helped her team improve patient care post-hospital discharge.

Moreover, Dr. Sherwood commented, the 16 Manhattan hospitals that participated in Mission: Lifeline cumulatively decided on a protocol to allow EMS to bypass the ED.

“This is the first time in New York City that all the PCI programs have gotten together,” said co-author Christopher Granger, MD, of Duke University (Durham, NC), in a press conference. “They said it could never be done…. It couldn’t have been done not on a regional basis.”

Competition as a Barrier

According to Dr. Granger, the biggest single barrier to improving is economic competition. “Each hospitals’ administration and CEO’s need to maximize their cardiovascular service load,” he commented. “But we have to get over that. When we get people together and focus on what is the best thing for the patient it’s so obvious that the people’s solutions are to come up with standardized approaches to measure feedback…And to compare the hospitals so each hospital sees how they are doing compared to every other hospital in the region. That’s a strong incentive for them to work more effectively to improve care.”

As for what comes next, Dr. Granger said “what we’re doing is taking the lessons from this and making them applicable to other regions that haven’t yet done this around the country. This really was a demonstration program.” He cited other countries such as Sweden that already have fully-integrated regional care systems in place, noting that the United States is “moving in that direction.”

Source:
Sherwood MW. Developing regional STEMI systems of care: final results of the Mission: Lifeline STEMI ACCELERATOR study. Presented at: American Heart Association Scientific Sessions; November 19, 2014; Chicago, IL.

Disclosure:

• The study was sponsored by Abiomed, AstraZeneca, Philips Healthcare, and The Medicines Company.
• Dr. Sherwood reports no relevant conflicts of interest.
• Dr. Granger reports receiving research grants from AstraZeneca, Bayer, BMS, DSI, Janssen, and The Medicines Company.

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