Patient and hospital determinants of primary percutaneous coronary intervention in England, 2003–2013

Abstract

ObjectivePrimary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is insufficiently implemented in many countries. We investigated patient and hospital characteristics associated with PPCI utilisation.MethodsWhole country registry data (MINAP, Myocardial Ischaemia National Audit Project) comprising PPCI-capable National Health Service trusts in England (84 hospital trusts; 92 350 hospitalisations; 90 489 patients), 2003–2013. Multilevel Poisson regression modelled the relationship between incidence rate ratios (IRR) of PPCI and patient and trust-level factors.ResultsOverall, standardised rates of PPCI increased from 0.01% to 86.3% (2003–2013). While, on average, there was a yearly increase in PPCI utilisation of 30% (adjusted IRR 1.30, 95% CI 1.23 to 1.36), it varied substantially between trusts. PPCI rates were lower for patients with previous myocardial infarction (0.95, 0.93 to 0.98), heart failure (0.86, 0.81 to 0.92), angina (0.96, 0.94 to 0.98), diabetes (0.97, 0.95 to 0.99), chronic renal failure (0.89, 0.85 to 0.90), cerebrovascular disease (0.96, 0.93 to 0.99), age >80 years (0.87, 0.85 to 0.90), and travel distances >30 km (0.95, 0.93 to 0.98). PPCI rates were higher for patients with previous percutaneous coronary intervention (1.09, 1.05 to 1.12) and among trusts with >5 interventional cardiologists (1.30, 1.25 to 1.34), more visiting interventional cardiologists (1–5: 1.31, 1.26 to 1.36; ≥6: 1.42, 1.35 to 1.49), and a 24 h, 7-days-a-week PPCI service (2.69, 2.58 to 2.81). Half of the unexplained variation in PPCI rates was due to between-trust differences.ConclusionsFollowing an 8 year implementation phase, PPCI utilisation rates stabilised at 85%. However, older and sicker patients were less likely to receive PPCI and there remained between-trust variation in PPCI rates not attributable to differences in staffing levels. Compliance with clinical pathways for STEMI is needed to ensure more equitable quality of care.

Association between time of hospitalization with acute myocardial infarction and in-hospital mortality

“…[21][22][23][24] For patients with NSTEMI, temporal improvements in survival were explained by an increase in the uptake of an invasive coronary strategy, 15 and for STEMI associated with the use of evidence-based pharmacotherapies and primary PCI. 25 The implementation of a national primary PCI programme has enabled 24/7 availability of guideline-recommended treatments in the UK, 15,26 although there remains variation across Europe. 27,28 Over the study period we found a decrease in absolute mortality, also noted by others, 23,29,30 but also a reduction in the variation in mortality associated with time of admission.…”

Prehospital diagnosis of patients with acute myocardial infarction

“…Terkelsen and colleagues demonstrated a more than 1 h reduction of system delay among patients diagnosed in the prehospital setting and triaged directly to PPCI, compared to patients without prehospital ECG recording and admission to a local hospital [16]. Prehospital ECG diagnosis has been successfully implemented worldwide and field triage directly to PPCI is associated with improved outcome, Figure 2 [17][18][19][20][21]. Danish nationwide data suggests that each additional hour spent is associated with a 10% relative increase in both mortality and the risk of heart failure [18,22], and that shorter system delays are associated with an increased proportion of patients returning to the labor market, Figure 3 [23].…”

Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature

“…, Hall et al . ); cardiovascular rehabilitation (Beswick et al . , Harrison & Wardle ); and stroke care (Rudd et al .…”