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A Geospatial Analysis of Emergency Transport and Inter-Hospital Transfer in ST-Segment Elevation Myocardial Infarction

  • Author Footnotes
    1 Dr. Concannon was supported by Grants RO1 HS010282 and T32 HS00060-12 from the Agency for Healthcare Research and Quality, Rockville, Maryland, and by the Tufts-NEMC Pfizer Career Development Award.
    Thomas W. Concannon
    Correspondence
    Corresponding author: Tel: 617-636-8441; fax: 617-636-0022.
    Footnotes
    1 Dr. Concannon was supported by Grants RO1 HS010282 and T32 HS00060-12 from the Agency for Healthcare Research and Quality, Rockville, Maryland, and by the Tufts-NEMC Pfizer Career Development Award.
    Affiliations
    Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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  • David M. Kent
    Affiliations
    Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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  • Sharon-Lise Normand
    Affiliations
    Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts

    Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
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  • Joseph P. Newhouse
    Affiliations
    Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts

    Kennedy School of Government, Harvard University, Cambridge, Massachusetts

    Faculty of Arts and Sciences, Harvard University, Cambridge, Massachusetts
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  • John L. Griffith
    Affiliations
    Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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  • Robin Ruthazer
    Affiliations
    Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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  • Joni R. Beshansky
    Affiliations
    Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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  • John B. Wong
    Affiliations
    Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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  • Thomas Aversano
    Affiliations
    Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland.
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  • Harry P. Selker
    Affiliations
    Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts
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  • Author Footnotes
    1 Dr. Concannon was supported by Grants RO1 HS010282 and T32 HS00060-12 from the Agency for Healthcare Research and Quality, Rockville, Maryland, and by the Tufts-NEMC Pfizer Career Development Award.
Published:November 23, 2007DOI:https://doi.org/10.1016/j.amjcard.2007.07.050
      Primary percutaneous coronary intervention (PCI) yields better outcomes than thrombolytic therapy in the treatment of patients with ST-segment elevation myocardial infarctions (STEMIs). Emergency medical service systems are potentially important partners in efforts to expand the use of PCI. This study was conducted to explore the probable impact on patient mortality and hospital volumes of competing strategies for the emergency transport of patients with STEMIs. Emergency transport was simulated for 2,000 patients with STEMIs from the Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT) trial in a geospatial model of Dallas County, Texas. Patient mortality estimates were obtained from a recently developed predictive model comparing PCI and thrombolytic therapy. A strategy of transporting patients to the closest hospital and treating with PCI if available and thrombolytic therapy if not yielded a 5.2% 30-day mortality rate (95% confidence interval [CI] 4.2% to 6.3%). A strategy of universal PCI, in which patients were transported only to PCI-capable hospitals, yielded 4.4% (95% CI 3.6% to 5.4%) mortality and an increase in patient volume at 2 full-time PCI hospitals of >1,000%. A strategy of targeted PCI, in which high-benefit patients were transported or transferred to PCI-capable hospitals, yielded 4.5% (95% CI 3.8% to 5.5%) mortality if transfers were decided in the emergency department and 4.2% (95% CI 3.4% to 5.1%) if transport was decided in the emergency vehicle. Targeted PCI strategies increased patient volumes at full-time PCI hospitals by about 700%. In conclusion, the selection of high-benefit patients for transport or transfer to PCI-capable hospitals can reduce mortality while minimizing major shifts in hospital patient volumes.
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