Abstract 195: The Importance Of Assessing Inter-regional Systems Of Healthcare In Patients With ST-Elevation Myocardial Infarction (STEMI): Examples From A Systematic Field Evaluation

Abstract

BACKGROUND: INESSS is a government-funded independent body that aids in evidence-based policy-making. Its cardiology evaluation unit recently completed a second systematic province-wide field evaluation of STEMI care in Quebec during a 6-month period in 2008-2009 in collaboration with a committee of clinical experts. The main objectives were to improve STEMI care by: 1) providing individual feedback to hospitals; and 2) identifying problems related to systems of STEMI care through analysis of inter-regional data. METHODS: At least 3 clinicians and 2 administrators of each of the 80 participating hospitals received a portrait of STEMI care for the province, their region and their hospital. Individual report cards ranked the healthcare region and the hospital for 14 measures of care. For the inter-regional analyses, we examined characteristics of existing networks of STEMI care such as the corridors of service for transfers for primary percutaneous coronary intervention (PPCI). RESULTS: At the provincial level, 82% of treated patients (n=1608) received PPCI. The majority (61%, n=987) were transferred from a non-tertiary centre with a median door-in door-out delay of 51 minutes (min) (10-90th percentile: 26-135) and a median door-to-device delay of 112 min (75-209). Notably, the 2 healthcare regions with the greatest number of STEMI patients had among the lowest proportions of patients treated (whether with PPCI or fibrinolysis) within recommended delays (39% and 32%, respectively). One of these regions had 9 community hospitals and a single PPCI center that did not have cardiac surgery-on-site (SOS) while the other region had 11 community hospitals and 6 PCI centers (1 no SOS and 5 SOS). In the latter region, >60% of STEMI patients had a direct admission PPCI but 3/6 centers had a median door-to-device time >90 min and there was a large variation in center volume. Only 22% of STEMI patients transferred for PPCI had a door-to device ≤90 min and choice of PPCI center was often not geographically optimal. Two PPCI centers received <5 transfers for PPCI. In the region with a single noSOS PPCI center, 76% of patients were transferred for PPCI but this center treated only 20% of these patients, 80% being sent to one of 4 PPCI centers in neighbouring regions. Only 19% of the transferred patients were treated ≤90 min, the median delay being 111 min (82-181). Sub-optimal utilization of the noSOS PPCI center in this region was also indicated by the low prevalence of direct admission PPCI (21%) compared with 2 other regions that had a single PPCI center (42% and 48%, respectively). CONCLUSIONS: Our province-wide evaluation of STEMI care indicates that it is important to examine systems of care as well as in-hospital processes. In 2 poorly-performing but high-output regions of Quebec, transfer for PPCI was the predominant choice of treatment of the community hospitals despite long delays. Moreover, recourse to certain PPCI centers appeared to be sub-optimal for both direct admission PPCI and transfer for PPCI. Thus, to improve systems of STEMI care, healthcare organizers must identify ways to optimize both choice of reperfusion strategy and corridors of service.