Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction

Abstract

IntroductionCalifornia has led successful regionalized efforts for several time-critical medical conditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandated protocols exist to define regionalization of care. We aimed to study the trends in regionalization of care for STEMI patients in the state of California and to examine the differences in patient demographic, hospital, and county trends.MethodsUsing survey responses collected from all California emergency medical services (EMS) agencies, we developed four categories – no, partial, substantial, and complete regionalization – to capture prehospital and inter-hospital components of regionalization in each EMS agency’s jurisdiction between 2005–2014. We linked the survey responses to 2006 California non-public hospital discharge data to study the patient distribution at baseline.ResultsSTEMI regionalization-of-care networks steadily developed across California. Only 14% of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population, but over half of these counties, representing 86% of California’s STEMI patient population, reached complete regionalization in 2014. We did not find any dramatic differences in underlying patient characteristics based on regionalization status; however, differences in hospital characteristics were relatively substantial.ConclusionPotential barriers to achieving regionalization included competition, hospital ownership, population density, and financial challenges. Minimal differences in patient characteristics can establish that patient differences unlikely played any role in influencing earlier or later regionalization and can provide a framework for future analyses evaluating the impact of regionalization on patient outcomes.

Differential benefits of cardiac care regionalization based on driving time to percutaneous coronary intervention

“…This framework compares changes in PCI access, PCI received, and health outcomes between communities with difficult versus easy access to PCI centers before and after STEMI regionalized networks were incorporated, taking into account time‐invariant underlying differences across counties. As published in detail elsewhere, 10 in 2006, only eight of 56 counties had regionalized, and the remaining 47 counties initiated their regionalization networks throughout the study period. By 2014, all 56 counties had at least partially regionalized.…”

“…These inpatient data were linked with vital statistics data to capture date of death using a unique patient identifier as well as nonpublic emergency department (ED) data from OSHPD to capture a complete patient cohort of anyone who had been seen or admitted to any nonfederal ED or hospital in California. We then used data from a validated survey (fully described elsewhere) 9,10 from all 33 local EMS agencies, comprising all 58 counties in the state. This data set identifies dates of implementation of STEMI regionalization and details of these protocols from each local EMS agency.…”

“…A regionalized STEMI network requires complex coordination of resources across the majority of hospitals, physician groups, health systems, and EMS agencies within a region implementing shared protocols, with regular feedback and measurement. We designed a survey (described fully elsewhere 9,10 ) that uses Class I recommendations from the AHA and ACC to objectively categorize the degree of regionalization of a STEMI network requiring: 1) an EMS in which patients with STEMI are directly transported to facilities that offer emergent PCI, bypassing hospitals that do not offer this care; and 2) interhospital transfer protocols specifically for patients with STEMI. 12 All local EMS agencies in California were surveyed, with a 100% response rate.…”

Initial treatment of uninsured patients with ST‐elevation myocardial infarction by facility percutaneous coronary intervention capabilities

“…13 This could be due to the robust state-level regionalization in PCI care found in California. 14 However, a key unanswered question-and the subject of this present studywas whether transfer is indicated among uninsured patients with STEMI. Specifically, whether uninsured patients with STEMI are more likely to receive initial treatment at PCI-capable hospitals.…”

Evaluation of STEMI Regionalization on Access, Treatment, and Outcomes Among Adults Living in Nonminority and Minority Communities

“…We designed a survey (described fully elsewhere 53,54 ) that objectively categorized a system's regionalization based on class I recommendations from the American College of Cardiology and American Heart Association categorization requiring that a STEMI regionalized network have an emergency medical system that instructs prehospital transport to directly transport patients with STEMI to facilities that offer emergency PCI, bypassing hospitals that do not offer it, and have interhospital transfer protocols specifically for patients with STEMI. 25 This survey was deployed across all local EMS agencies in California and achieved a 100% response rate.…”