Key result
STEMI regionalization increased admission to PCI-capable hospitals by 9.4% and same-day PCI by 11.2% for patients living ≥30 minutes from a PCI center, with no mortality benefits observed.
Why the study?
It was unknown whether the benefits of STEMI regionalization depend on a community's baseline distance to its nearest PCI center.
Does STEMI regionalization improve access to PCI and reduce mortality in STEMI patients depending on baseline distance to the nearest PCI center?
Observational (n=139,408)
Yes
Does STEMI regionalization improve access to PCI and reduce mortality in STEMI patients depending on baseline distance to the nearest PCI center?
STEMI regionalization efforts significantly improve access and treatment rates primarily for patients living ≥30 minutes from a PCI center, though without demonstrated mortality benefits.
No mortality benefit despite improved PCI access warrants caution before policy adoption; leaves open effects on outcomes in remote populations.
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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Shen et al. (2020) conducted an observational in ST-elevation myocardial infarction (STEMI) (n=139,408). STEMI regionalization vs. Pre-regionalization / communities <30 minutes from PCI center was evaluated on Admission to a PCI-capable hospital, receipt of same-day PCI, receipt of PCI during hospitalization, and mortality. STEMI regionalization increased admission to PCI-capable hospitals by 9.4% and same-day PCI by 11.2% for patients living ≥30 minutes from a PCI center, with no mortality benefits observed.
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