Regional Systems of Care Demonstration Project

Jollis, James G.; Al‐Khalidi, Hussein R.; Roettig, Mayme L.; Berger, Peter B.; Corbett, Claire C.; Dauerman, Harold L.; Fordyce, Christopher B.; Fox, Keith A.A.; Garvey, J. Lee; Gregory, Tammy; Henry, Timothy D.; Rokos, Ivan C.; Sherwood, Matthew W.; Suter, Robert E.; Wilson, B. Hadley; Granger, Christopher B.

doi:10.1161/circulationaha.115.019474

Cited by 82 publications

(29 citation statements)

References 29 publications

(24 reference statements)

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“…The project involved 484 hospitals (171 PCI‐capable hospitals) and 1253 EMS agencies in 16 regions using standard data collection and regional treatment protocols from 2012 to 2014 7, 8. We found that quality of care improved for EMS‐transported patients with STEMI with and without OHCA.…”

Section: Discussionmentioning

confidence: 98%

“…This study uses data from the Mission: Lifeline STEMI Accelerator project that was organized and executed between July 1, 2012 (2012Q3), and March 31, 2014 (2014Q1), in 16 US regions 7, 8. The intervention was initiated on the basis that, although the number of PCI‐capable hospitals in recent years has increased by almost 50% and 90% of Americans currently live within 60 minutes of a PCI‐capable facility, the organization of the healthcare system, including a highly fragmented EMS system, hinders coordination between EMS providers and hospitals 8.…”

Section: Methodsmentioning

confidence: 99%

“…The intervention was initiated on the basis that, although the number of PCI‐capable hospitals in recent years has increased by almost 50% and 90% of Americans currently live within 60 minutes of a PCI‐capable facility, the organization of the healthcare system, including a highly fragmented EMS system, hinders coordination between EMS providers and hospitals 8. Ultimately, this leads to system delays and a substantial number of patients who do not meet guideline‐recommended goals of timely intervention 8. Moreover, there is competition among hospitals and physician groups that is a barrier to coordinated care 8.…”

Section: Methodsmentioning

confidence: 99%

“…Ultimately, this leads to system delays and a substantial number of patients who do not meet guideline‐recommended goals of timely intervention 8. Moreover, there is competition among hospitals and physician groups that is a barrier to coordinated care 8. Because this fragmentation and competition among hospitals and physician groups have hindered the establishment of coordinated treatment plans, procedures, and common regional approaches, Mission: Lifeline STEMI Accelerator aimed to improve regional STEMI patient care through the development of leadership teams, coordinated protocols, shared data collection, and feedback systems for US‐based hospitals and EMS agencies.…”

Section: Methodsmentioning

confidence: 99%

“…Patients with cardiac arrest at the time of first medical contact (FMC) were registered in the Mission: Lifeline STEMI Accelerator project, which represents the largest national effort to coordinate regional STEMI care between hospitals and emergency medical service (EMS) agencies in 16 US regions from 2012 to 2014 7, 8. Using data from the Mission: Lifeline STEMI Accelerator project, we evaluated whether changes in care and outcomes after these initiatives equally applied to patients with and without OHCA.…”

Section: Introductionmentioning

confidence: 99%

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Improvement in Care and Outcomes for Emergency Medical Service–Transported Patients With ST‐Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study

Kragholm

Chiswell

et al. 2017

JAHA

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BackgroundPatients with ST‐elevation myocardial infarction (STEMI) with out‐of‐hospital cardiac arrest (OHCA) may benefit from direct transport to a percutaneous cardiac intervention (PCI) hospital but have previously been less likely to bypass local non‐PCI hospitals to go to a PCI center.Methods and ResultsWe reported time trends in emergency medical service transport and care of patients with STEMI with and without OHCA included from 171 PCI‐capable hospitals in 16 US regions with participation in the Mission: Lifeline STEMI Accelerator program between July 1, 2012, and March 31, 2014. Time trends by quarter were assessed using logistic regression with generalized estimating equations to account for hospital clustering. Of 13 189 emergency medical service–transported patients, 88.7% (N=11 703; 10.5% OHCA) were taken directly to PCI hospitals. Among 1486 transfer‐in patients, 21.7% had OHCA. Direct transport to a PCI center for OHCA increased from 74.7% (July 1, 2012) to 83.6% (March 31, 2014) (odds ratio per quarter, 1.07; 95% confidence interval, 1.02–1.14), versus 89.0% to 91.0% for patients without OHCA (odds ratio, 1.03; 95% confidence interval, 0.99–1.07; interaction P=0.23). The proportion with prehospital ECGs increased for patients taken directly to PCI centers (53.9%–61.9% for those with OHCA versus 73.9%–81.9% for those without OHCA; interaction P=0.12). Of 997 patients with OHCA taken directly to PCI hospitals and treated with primary PCI, first medical contact‐to‐device times within the guideline‐recommended goal of ≤90 minutes were met for 34.5% on July 1, 2012, versus 41.8% on March 31, 2014 (51.6% and 56.1%, respectively, for 9352 counterparts without OHCA; interaction P=0.72).ConclusionsDirect transport to PCI hospitals increased for patients with STEMI with and without OHCA during the 2012 to 2014 Mission: Lifeline STEMI Accelerator program. Proportions with prehospital ECGs and timely reperfusion increased for patients taken directly to PCI hospitals.

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Section: Discussionmentioning

confidence: 98%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Improvement in Care and Outcomes for Emergency Medical Service–Transported Patients With ST‐Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study

Kragholm

Chiswell

et al. 2017

JAHA

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Percutaneous Coronary Intervention Without On-site Cardiac Surgery

Anderson

2017

JAMA Cardiol

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Since its introduction almost 40 years ago, the procedural safety of percutaneous coronary intervention (PCI) has improved enormously. In particular, the need for emergency coronary artery bypass grafting (CABG) has strikingly diminished, although it has not been eliminated. In consequence of this remarkable achievement, the requirement that PCI should be conducted only in centers with cardiac surgery available on-site has been gradually relaxed. In parallel with this change, primary PCI (PPCI) as immediate treatment for acute ST-elevation myocardial infarction (STEMI) has been shown to be superior therapy when it can be performed rapidly after infarction onset. These 2 forces together have led to growth in the number of centers with catheterization facilities that perform PCI without on-site cardiac surgery. Many of these centers are smaller hospitals in rural or suburban areas, and part of the justification was that they can be more rapidly and easily accessible to patients with STEMI than the more urban and distant hospitals with on-site surgical availability. Studies show that these smaller centers also are performing PCI for indications other than STEMI, that is, for urgent, nonurgent, and elective indications.For several years researchers have been examining whether PCI performed at centers without on-site cardiac surgery have worse outcomes, usually measured as mortality, compared with centers that have on-site surgery. The results so far have been uniformly negative; that is, it has never been demonstrated that clinical outcomes are any different (worse or better) at centers without on-site cardiac surgery compared with those with it. In this issue of JAMA Cardiology, Goel and colleagues 1 provide additional confirmatory evidence for this lack of difference. Using data from the National Inpatient Sample (NIS) comprising almost 7 million PCI procedures, these investigators again examined the question. The PCI procedures at both types of centers were categorized by clinical indication: STEMI, non-ST-elevation acute coronary syndrome (NSTE-ACS), or elective PCI. Although unadjusted mortality rates were lower at centers with cardiac surgery on-site, after multivariate adjustment there were no differences in mortality between the 2 types for any of the 3 indications. These results echo many other reports. [2][3][4][5] There are 2 findings within these new data that are worth noting. First, the investigators demonstrate quantitatively that the proportion of PCI procedures performed at hospitals without on-site cardiac surgery is increasing. Over the 10 years examined, the proportion of procedures performed at centers without on-site surgery programs

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

2020

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IMPORTANCE Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities.OBJECTIVE To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties. DESIGN, SETTING, AND PARTICIPANTSThis cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-indifference-in-differences estimation approach. EXPOSURE Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization. MAIN OUTCOMES AND MEASURES Access to percutaneous coronary intervention (PCI)-capablehospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality. RESULTSThis study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, −2.8 to −0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization.

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Regional Systems of Care Demonstration Project

Cited by 82 publications

References 29 publications

Improvement in Care and Outcomes for Emergency Medical Service–Transported Patients With ST‐Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study

Improvement in Care and Outcomes for Emergency Medical Service–Transported Patients With ST‐Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study

Percutaneous Coronary Intervention Without On-site Cardiac Surgery

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

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