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Differential benefits of cardiac care regionalization based on driving time to percutaneous coronary intervention
Yu-Chu Shen1,2, Renee Y Hsia3,4
1Graduate School of Defense Management, Naval Postgraduate School, Monterey, California, USA.
Insights
Regionalization of ST-elevation myocardial infarction (STEMI) care benefits patients living further from percutaneous coronary intervention (PCI) centers. Communities closer to PCI centers did not see significant improvements from these regionalization initiatives.
Area of Science:
- Cardiology
- Health Services Research
- Public Health
Background:
- ST-elevation myocardial infarction (STEMI) requires timely reperfusion therapy, with percutaneous coronary intervention (PCI) reducing morbidity and mortality.
- Regionalization of STEMI care aims to improve timeliness and PCI utilization.
- The impact of regionalization on STEMI care outcomes based on patient proximity to PCI centers remains unclear.
Purpose of the Study:
- To determine if the benefits of STEMI regionalization, including PCI access, timeliness, and mortality, vary by a community's baseline distance to the nearest PCI center.
- To assess disparities in STEMI care related to distance from PCI-capable hospitals.
Main Methods:
- A difference-in-difference-in-differences model was employed to analyze data from January 1, 2006, to September 30, 2015.
- Examined patient access to PCI-capable hospitals, receipt of PCI (same-day or during hospitalization), and health outcomes.
- Compared outcomes for patients based on their community's driving time to the nearest PCI center (<30 minutes vs. ≥30 minutes).
Main Results:
- For communities ≥30 minutes from a PCI center, regionalization increased PCI-capable hospital admission by 9.4% and same-day PCI likelihood by 11.2%.
- Patients living <30 minutes from a PCI center did not experience significant benefits from regionalization initiatives.
- Regionalization efforts reduced access disparities by over 50% and eliminated treatment disparities for communities farther from PCI centers.
Conclusions:
- Benefits of STEMI regionalization, in terms of PCI access and timeliness, were primarily observed in communities located ≥30 minutes from the nearest PCI center.
- No significant mortality benefits of regionalization were found to be dependent on distance to PCI centers.
- Future STEMI regionalization efforts should prioritize communities with limited existing access to PCI-capable hospitals.
Background:
Patients with ST-elevation myocardial infarction (STEMI) require timely reperfusion, and percutaneous coronary intervention (PCI) decreases morbidity and mortality. Regionalization of STEMI care has increased timeliness and use of PCI, but it is unknown whether benefits to regionalization depend on a community's distance from its nearest PCI center. We sought to determine whether STEMI regionalization benefits, measured by access to PCI centers, timeliness of treatment (same-day or in-hospital PCI), and mortality, differ by baseline distance to nearest PCI center.
Methods:
Using a difference-in-difference-in-differences model, we examined access to PCI-capable hospitals, receipt of PCI either on the day of admission or during the care episode, and health outcomes for patients hospitalized from January 1, 2006, to September 30, 2015.
Results:
Of 139,408 patients (2006 to 2015), 51% could reach the nearest PCI center in <30 minutes, and 49% required ≥30 minutes driving time. For communities with baseline access ≥30 minutes, regionalization increased the probability of admission to a PCI-capable hospital by 9.4% and also increased the likelihood of receiving same-day PCI (by 11.2%) and PCI during the hospitalization (by 7.4%). Patients living within 30 minutes did not accrue significant benefits (measured by admission to a PCI-capable hospital or receipt of PCI) from regionalization initiatives. Regionalization more than halved access disparities and completely eliminated treatment disparities between communities ≥30 minutes and communities <30 minutes from the nearest PCI hospital.
Conclusions:
Measured by likelihood of admission to a PCI-capable facility and receipt of PCI, benefits of STEMI regionalization in California accrued only to patients whose nearest PCI center was ≥30 minutes away. We found no mortality benefits of regionalization based on distance from PCI center. Our results suggest that policymakers focus STEMI regionalization efforts in communities that are not already well serviced by PCI-capable hospitals.
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