Effectiveness of regionalized systems for stroke and myocardial infarction

Abstract

BackgroundAcute 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.MethodsLiterature 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.ResultsFor 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.ConclusionAlthough 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.

Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA

“…The narrow time frame for therapeutic administration, which in the UK and AUS is within 4.5 h of symptom onset and in the USA is within 3 (approved indication) or 4.5 (guidelines) h, is one main factor for low treatment rates. However, improved rtPA treatment rates are possible when internal hospital organisational factors are addressed [9-12], and when regional stroke systems are operationalised to support patients with acute stroke [13-16]. …”

Time Delays in Acute Myocardial Infarction – the Gender Perspective

“…Some of these networks have been proved to represent real life-saving therapies, as the implementation of primary revascularization in ST-elevation myocardial infarction (STEMI) within a well-organized system led to a spectacular reduction in STEMI-related mortality. [1][2][3] In an attempt to make the STEMI networks highly effi- 6 According to this study, fewer women than men presented to the hospital in the first 12 hours after angina onset. Interestingly, the authors also demonstrated that in women from this geographical area, coronary events began more frequently in the morning with atypical symptoms.…”

Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care?

“… 8 , 24 ST‐Elevation Myocardial Infarction: STEMI regionalized care started in 2004 when the American College of Cardiology/American Heart Association (ACA/AHA) established “door‐to‐balloon” time targets in STEMI. 25 In 2007, the Mission: Lifeline program was started to provide recognition and accelerate regionalization efforts. 26 The Joint Commission as of 2019 has offered 2 voluntary certifications for STEMI care.…”