Key result
Regionalized AIS and STEMI care improves process metrics but shows no independent outcome benefit.
Why the study?
Does delivery of care within formally regionalized systems at designated centers improve process times, access to reperfusion, and clinical outcomes compared to non- or pre-regionalized care in patients with acute ischemic stroke and ST-segment elevation myocardial infarction?
Does delivery of care within formally regionalized systems at designated centers improve process times, access to reperfusion, and clinical outcomes compared to non- or pre-regionalized care in patients with acute ischemic stroke and ST-segment elevation myocardial infarction?
Answers are grounded in this paper and cite their sources.
While regionalized systems of care for AIS and STEMI improve care processes and expand reperfusion access, their independent impact on mortality remains difficult to separate from broader secular improvements and patient presentation factors, warranting future randomized registry or cluster-randomized trials.
BACKGROUND: Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI. METHODS: Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement. RESULTS: For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems. CONCLUSION: Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
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Rhudy et al. (2015) conducted a review in Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI). Formally regionalized systems of care at designated centers (such as Joint Commission-certified primary or comprehensive stroke centers and PPCI-capable STEMI systems) with EMS bypass of lesser or non-designated centers vs. Non-regionalized or pre-regionalized systems of care was evaluated on Clinical and functional outcomes, mortality, process times, and access/reperfusion rates (e.g., rt-PA utilization and PPCI). Regionalized care for AIS and STEMI enhances process metrics and reduces unadjusted disparities, but outcome differences become nonsignificant after adjusting for delayed arrival and non-EMS transport.
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