Comparative effectiveness of ST-segment-elevation myocardial infarction regionalization strategies
Thomas W Concannon1, David M Kent, Sharon-Lise Normand
1Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA. tconcannon@tuftsmedicalcenter.org
Insights
Transporting all ST-segment-elevation myocardial infarction patients to PCI-capable hospitals via emergency medical services is more effective and less costly than building new cardiac catheterization labs. This strategy improves PCI access and patient outcomes.
Area of Science:
- Cardiology
- Health Services Research
- Public Health
Background:
- Primary percutaneous coronary intervention (PCI) is superior to fibrinolytic therapy for ST-segment-elevation myocardial infarction (STEMI).
- Most US hospitals lack PCI capabilities, leading to continued reliance on fibrinolytic therapy.
- Regionalization strategies aim to increase PCI use for STEMI patients.
Purpose of the Study:
- To evaluate the comparative effectiveness of regionalization strategies for increasing PCI use in STEMI.
- To compare hospital-based PCI expansion with an emergency medical services (EMS)-based transport strategy.
Main Methods:
- Simulated emergency care for 2000 STEMI patients in a regional hospital system.
- Compared a base case (standard care) with 12 hospital-based strategies (new labs, extended hours) and 1 EMS-based strategy (transport to PCI-capable hospitals).
- Estimated incremental costs and quality-adjusted life years (QALYs) saved.
Main Results:
- The base case resulted in 609 patients receiving PCI.
- Hospital-based strategies increased PCI use, costs, and QALYs, proving cost-effective.
- The EMS-based strategy of transporting all STEMI patients to existing PCI facilities was less costly and more effective than hospital expansion.
Conclusions:
- New construction and staffing of PCI laboratories may not be necessary.
- An EMS-based strategy for STEMI patient transport to PCI-capable hospitals is recommended if feasible.
- This approach optimizes resource allocation and improves patient outcomes for STEMI.
Background:
Primary percutaneous coronary intervention (PCI) is more effective on average than fibrinolytic therapy in the treatment of ST-segment-elevation myocardial infarction. Yet, most US hospitals are not equipped for PCI, and fibrinolytic therapy is still widely used. This study evaluated the comparative effectiveness of ST-segment-elevation myocardial infarction regionalization strategies to increase the use of PCI against standard emergency transport and care.
Methods And Results:
We estimated incremental treatment costs and quality-adjusted life expectancies of 2000 patients with ST-segment-elevation myocardial infarction who received PCI or fibrinolytic therapy in simulations of emergency care in a regional hospital system. To increase access to PCI across the system, we compared a base case strategy with 12 hospital-based strategies of building new PCI laboratories or extending the hours of existing laboratories and 1 emergency medical services-based strategy of transporting all patients with ST-segment-elevation myocardial infarction to existing PCI-capable hospitals. The base case resulted in 609 (95% CI, 569-647) patients getting PCI. Hospital-based strategies increased the number of patients receiving PCI, the costs of care, and quality-adjusted life years saved and were cost-effective under a variety of conditions. An emergency medical services-based strategy of transporting every patient to an existing PCI facility was less costly and more effective than all hospital expansion options.
Conclusion:
Our results suggest that new construction and staffing of PCI laboratories may not be warranted if an emergency medical services strategy is both available and feasible.
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