Abstract 18115: Are State Policies to Permit Pre-hospital Bypass Associated With Better Treatment Patterns Among Patients With ST-Elevation Myocardial Infarction? A Report From AHA's Mission: Lifeline Program

Abstract

Introduction: Early success with regionalization of STEMI care has led many states to adopt statewide pre-hospital STEMI destination policies, allowing emergency medical services (EMS) to bypass non-PCI capable hospitals. The association with adoption of these policies and patterns of care among STEMI patients is unknown. Hypothesis: Compared with similar states without STEMI bypass policies, we hypothesized states with bypass policies would have a higher proportion of eligible STEMI patients 1) arrive by direct EMS transport to PCI hospitals (less transfer-in); 2) receive any reperfusion; and 3) receive timely PCI. Methods: Using data from Jan 1, 2013 to Dec 31, 2014 from the NCDR ACTION Registry, six states with bypass policies (cases) were matched to six states without bypass policies (controls) a priori on region, hospital density, and percent state participation in the registry. Using the matched sample, logistic regression models were adjusted for patient- and state-level characteristics. Outcomes were: 1) transfer-in status, 2) receipt of reperfusion, and 3) receipt of timely PCI. Results: Case states: Delaware, Iowa, Maryland, North Carolina, Pennsylvania, and Massachusetts, were matched to the respective control states: South Carolina, Minnesota, Virginia, Texas, New York and Connecticut, with 19,287 patients at 379 sites. Patients from states with bypass policies were similar in age, gender, and comorbidities to patients from states without bypass policies. They were more likely to be white, have private insurance, and reside in rural areas. They were less likely to transfer into a PCI hospital (aOR=0.60, 95% CI 0.26-1.35) and more likely to receive reperfusion therapy (aOR=1.77, 95% CI 0.96-3.24), but these trends were not statistically significant. They were also significantly more likely to receive primary PCI within 90 minutes (aOR=1.59, 95% CI 1.19-2.12) or 120 minutes (aOR=1.44, 95% CI 1.06-1.95) of first medical contact. Conclusions: Statewide adoption of STEMI destination policies allowing EMS to bypass non-PCI capable facilities is associated with shorter time from first medical contact to PCI and non-significant trends toward increased arrival by direct EMS transport and more receipt of reperfusion therapy.