Universal access to a percutaneous coronary intervention hospital: is it feasible or desirable?

The Chasm in Percutaneous Coronary Intervention and In-Hospital Mortality Rates Among Acute Myocardial Infarction Patients in Rural and Urban Hospitals in China: A Mediation Analysis

Objectives: To determine to what extent the inequality in the ability to provide percutaneous coronary intervention (PCI) translates into outcomes for AMI patients in China.

Methods: We identified 82,677 patients who had primary diagnoses of AMI and were hospitalized in Shanxi Province, China, between 2013 and 2017. We applied logistic regressions with inverse probability weighting based on propensity scores and mediation analyses to examine the association of hospital rurality with in-hospital mortality and the potential mediating effects of PCI.

Results: In multivariate models where PCI was not adjusted for, rural hospitals were associated with a significantly higher risk of in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 1.03–1.37). However, this association was nullified (OR: 0.94, 95% CI: 0.81–1.08) when PCI was included as a covariate. Mediation analyses revealed that PCI significantly mediated 132.3% (95% CI: 104.1–256.6%) of the effect of hospital rurality on in-hospital mortality. The direct effect of hospital rurality on in-hospital mortality was insignificant.

Conclusion: The results highlight the need to improve rural hospitals’ infrastructure and address the inequalities of treatments and outcomes in rural and urban hospitals.

Prognostic Implications of Door-to-Balloon Time and Onset-to-Door Time on Mortality in Patients With ST -Segment-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Background In patients with ST-segment-elevation myocardial infarction, timely reperfusion therapy with door-to-balloon (D2B) time <90 minutes is recommended by the current guidelines. However, whether further shortening of symptom onset-to-door (O2D) time or D2B time would enhance survival of patients with ST-segment-elevation myocardial infarction remains unclear. Therefore, the current study aimed to evaluate the prognostic impact of O2D or D2B time in patients with ST-segment-elevation myocardial infarction who underwent primary percutaneous coronary intervention. Methods and Results We analyzed 5243 patients with ST-segment-elevation myocardial infarction were treated at 20 tertiary hospitals capable of primary percutaneous coronary intervention in Korea. The association between O2D or D2B time with all-cause mortality at 1 year was evaluated. The median O2D time was 2.0 hours, and the median D2B time was 59 minutes. A total of 92.2% of the total population showed D2B time ≤90 minutes. In univariable analysis, 1-hour delay of D2B time was associated with a 55% increased 1-year mortality, whereas 1-hour delay of O2D time was associated with a 4% increased 1-year mortality. In multivariable analysis, D2B time showed an independent association with mortality (adjusted hazard ratio, 1.90; 95% CI , 1.51-2.39; P<0.001). Reducing D2B time within 45 minutes showed further decreased risk of mortality compared with D2B time >90 minutes (adjusted hazard ratio, 0.30; 95% CI , 0.19-0.42; P<0.001). Every reduction of D2B time by 30 minutes showed continuous reduction of 1-year mortality (90 to 60 minutes: absolute risk reduction, 2.4%; number needed to treat, 41.9; 60 to 30 minutes: absolute risk reduction, 2.0%; number needed to treat, 49.2). Conclusions Shortening D2B time was significantly associated with survival benefit, and the survival benefit of shortening D2B time was consistently observed, even <60 to 90 minutes.

Percutaneous Coronary Intervention in the United States: Risk Factors for Untimely Access

OBJECTIVE

To determine how access to percutaneous coronary intervention (PCI) is distributed across demographics.

DATA SOURCES

Secondary data from the 2011 American Hospital Association (AHA) survey data combined with 2010 Census.

STUDY DESIGN

We calculated prehospital times from 32,370 ZIP codes to the nearest PCI center. We used a multivariate logit model to determine the odds of untimely access by the ZIP code's concentration of vulnerable populations.

DATA COLLECTION

We used ZIP code-level data on community characteristics from the 2010 Census and supplemented it with 2011 AHA survey data on service-line availability of PCI for responding hospitals.

PRINCIPAL FINDINGS

For approximately 306 million Americans, the median prehospital time to the nearest PCI center is 33 minutes. While 84 percent of Americans live within one hour of a PCI center, the odds of untimely access are higher in low-income (OR: 3.00; 95 percent CI: 2.39, 3.77), rural (8.10; 95 percent CI: 6.84, 9.59), and highly Hispanic communities (2.55; 95 percent CI: 1.86, 3.49).

CONCLUSIONS

While the majority of Americans live within 60 minutes of a PCI center, rural, low-income, and highly Hispanic communities have worse PCI access. This may translate into worse outcomes for patients with acute myocardial infarction.