Transcript Utilization of EMS Transport Among Patients with STEMI

Utilization of EMS Transport
Among Patients with STEMI
Findings from the National Cardiovascular Data
ACTION Registry–Get With The Guidelines
Robin Mathews, Eric Peterson, Shuang Li, Matthew Roe,
Stephen Wiviott, Jorge Saucedo, Elliott Antman, Tracy Wang
STEMI: Time is Muscle
ACC/AHA Guidelines for STEMI Care
• Early evaluation (e.g., pre-hospital ECG)
• Pre-hospital stabilization
• Expedited triage by receiving hospital
NRMI data (1990s) showed only 50% EMS use
Antman, EM, 2004 JACC (45); 671-719
Canto, JG. 2002 Circulation (106): 3018-3023
Gaps in the Data

What are contemporary patterns of EMS vs.
self transport use among STEMI patients?

What are the barriers to EMS utilization?

Does EMS use improve timeliness of
subsequent treatment?
ACTION Registry®-GWTG™
STEMI population
Jan 01, 2007-SEP 30, 2009
Missing mode of transport
Transfer- in patients
Missing home zip code information
Study Population
18,069 patients, 296 hospitals
Self Transport
6,988 patients
38.7 %
EMS Transport
11,081 patients
61.3 %
Sociodemographic Factors Associated with EMS-Transport
Age (per 5 yr increase)
Distance (vs. < 4 miles)
4 – 10 miles
> 10 miles
Hospital Region (vs. Midwest)
West
South
Northeast
Insurance status (vs. HMO/Pvt)
Medicare
Medicaid /Military/VA
Self/none
Hispanic ethnicity
Male
Adjusted
χ2
143
53
Adjusted
OR
95% CI
1.09
1.08-1.10
1.14
1.64
1.04-1.25
1.47-1.82
1.22
1.43
1.54
0.97-1.54
1.20-1.69
1.18-2.04
1.06
1.35
1.16
0.74
0.87
0.97-1.15
1.16-1.59
1.06-1.28
0.63-0.85
0.81-0.94
20
19
17
13
*Other variables in this model: dyslipidemia, diabetes mellitus, prior HF, HTN, atrial fibrillation/atrial flutter, prior MI, prior stroke, BMI, heart rate, dialysis,
educational level, income level, race, time of presentation, rural vs. urban location
Clinical Factors Associated with EMS-Transport
Adjusted
OR
95% CI
1.15
1.15-1.16
Heart Failure only
1.25
1.14-1.39
Shock only
1.96
1.69-2.33
Heart Failure and Shock
1.82
1.56-2.13
Adjusted
χ2
Lower systolic BP (per 10)
862
Heart failure symptoms
75
Prior Heart Failure
27
1.35
1.20-1.51
Prior stroke
25
1.30
1.18-1.43
Prior CABG
20
0.82
0.75-0.89
Prior PCI
18
1.16
1.09-1.25
EMS Transport Reduces Symptom Onset to Hospital
Arrival Time Regardless of Distance Traveled
Self
600
Time (min)
500
400
300
200
100
0
< 4 miles
P-value
<0.0001
4-10 miles
<0.0001
>10 miles
<0.0001
EMS
Treatment Differences Between
EMS- and Self-Transport
140
120
100
31 min
80
60
40
20
0
9
8
7
6
5
4
3
2
1
0
80
70
3 min
60
50
Self
EMS
40
30
20
10
0
Time to ECG
Symptom onset to
arrival
Adjusted OR (95%CI)
Sx onset to arrival ≤ 120 min
0.55 (0.50-0.60)
13 min
D2B
P<0.001 for all
Time to ECG ≤ 10 min
0.52 (0.46-0.59)
D2B ≤ 90 min
0.43 (0.37-0.50)
Limitations

Income and educational levels derived from home zip
code and census data.

Distance traveled derived from home to hospital zip code
and only approximates the travel distance for an
individual patient

ACTION-GWTG did not capture symptom severity

.
Conclusions

EMS continues to be underutilized among STEMI
patients in contemporary practice

Estimates of socioeconomic factors, such as
household income and insurance status, did not
predict EMS utilization

Patients who use EMS have significantly shorter
delays to presentation and treatment, even among
patients who live close to the hospital
Implications

EMS use, by reducing the delay from symptom
onset to hospital arrival alone, is associated with a
>30 minute reduction in ischemic time

More work is needed to promote EMS use as
emphasized by Mission Lifeline’s ‘chain of survival’

Community education efforts should be tailored to
groups that underutilize EMS and integrated with
system-wide strategies to promote the timely use of
reperfusion