Health Services Research & Development

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2006 HSR&D National Meeting Abstract


1064 — Factors Associated with Reperfusion for ST Segment Elevation MI Patients in VHA Facilities

Author List:
McDermott KA (VA Puget Sound HCS)
Lowy E (VA Puget Sound HCS)
Sales AE (VA Puget Sound HCS)
Fihn SD (VA Puget Sound HCS)

Objectives:
Guidelines recommend reperfusion either through fibrinolytics or percutaneous coronary intervention (PCI) within a narrow timeframe (30 minutes for fibrinolytics, 120 minutes for PCI); our goal was to assess the association of patient and facility characteristics with receipt of guideline-recommended reperfusion across VHA.

Methods:
Used national 100% sample of inpatients discharged with diagnosis of acute myocardial infarction (AMI) from External Peer Review Program (EPRP), including only patients experiencing ST segment elevation MI (STEMI). Patient factors come from EPRP data and national databases at Austin, including age, time since symptom onset, and symptoms at presentation. Facility factors come from an inventory of VHA facilities, including size and cardiac procedure capability. We used multivariate logistic regression with cluster correction to assess the relationship between these factors and timely reperfusion.

Results:
1218 patients out of 6619 (18%) had STEMI by EKG on initial presentation. Median time to reperfusion was 46.5 minutes for patients receiving fibrinolytics, and 145 minutes for patients receiving PCI. 629 of 1218 patients (51%) did not receive reperfusion. Among patient characteristics, symptoms of pain and diaphoresis were positively associated (ORs 1.91 and 1.84 respectively) and age and longer time since symptom onset were negatively associated (ORs 0.98 and 0.44) with receiving reperfusion within guideline-recommended times. Facilities with full cardiac capability, including cardiothoracic surgery, were most likely to achieve timely reperfusion. Compared to full capability hospitals, hospitals without cardiac facilities were least likely to achieve reperfusion (OR 0.23), followed by hospitals with PCI capacity (0.32), then hospitals with catheterization but not PCI capacity (0.52).

Implications:
VHA treats a relatively low proportion of patients with STEMI, and this reflects low volume and other practice conditions that differ from non-VA settings. While the finding that patients with relatively clear cardiac symptoms are more likely to receive timely reperfusion reflects appropriate clinical care, the finding that being treated in a hospital with PCI capabilities leads to lower likelihood of receiving timely reperfusion than being treated in a hospital with catheterization capacity only is disturbing.

Impacts:
Reperfusion within guideline-recommended timeframes reflects life-preserving care. These findings indicate directions for further quality improvement and research to ascertain causes of performance gaps.