SNOWMASS, COLO. – Competition among hospitals and between cardiology groups constitutes the greatest barrier to well-functioning regional networks for ST-elevation myocardial infarction therapy, according to Dr. Bernard J. Gersh.
"We’ve got the resources in this country, but we are competitive. That’s the name of the game. So this is a real challenge. It’s an area where the state chapters of the American College of Cardiology could really help," said Dr. Gersh, professor of medicine at the Mayo Clinic, Rochester, Minn.
Dr. Bernard Gersh
The 2013 ACC/American Heart Association STEMI (ST-elevation myocardial infarction) guidelines list as a class I recommendation that "each community should develop a STEMI system of care." But a one-size-fits-all approach won’t work. Creating an efficient network to deliver reperfusion therapy to as many STEMI patients as quickly as possible in Los Angeles, where there is seemingly a percutaneous coronary intervention (PCI) center every few blocks, poses a very different set of challenges than in, say, Wyoming, with two cardiac catheterization laboratories to serve nearly a 100,000–square mile area, the cardiologist said.
He recalled a recent conversation with a colleague from a midsize Eastern city with four PCI hospitals. All four run three call schedules per 24 hours so an interventional cardiologist is always available. But collectively the hospitals handle an average of only five or six STEMIs per week.
"Can you really justify that? It’s just not a good allocation of resources. Furthermore, if you look at all the epidemiology coming out of the U.S. and the Western World, STEMI is in decline. Only about 30% of MIs now are STEMIs, and it’s going to be less and less," Dr. Gersh continued.
He said he admires the approach taken in Vienna. Three hospital systems serve this capital city of 1.7 million. Each system keeps its PCI center open from 8 a.m. to 5 p.m. After 5, however, the three PCI hospitals alternate call. The ambulance is diverted to go directly to the hospital whose catheterization lab is kept open that night.
"They can do that in Vienna. Can we do that here? I don’t know," he said at the annual cardiovascular conference at Snowmass.
Dr. Gersh noted that the American Heart Association Mission: Lifeline program, which was created to increase timely access to PCI for STEMI patients, recently published the first-ever national survey of regional STEMI systems. The purpose was to identify best practices, financing strategies, and barriers to system implementation. Responses were obtained from 381 STEMI networks with 899 PCI hospitals.
The single most commonly cited barrier to network implementation and optimal functioning was hospital competition, identified as a significant problem in 37% of the systems. Next came emergency medical services (EMS) transport and finances, cited by 26% of respondents. The third most common barrier was competition between cardiology groups, which was an issue in 21% of networks.
The predominant funding sources for STEMI systems were PCI hospitals and cardiology practices.
Based on his favorable personal experience with the Mayo Clinic STEMI network, which uses three helicopters, an airplane, and ground ambulances to serve 28 hospitals as far as 150 miles away, Dr. Gersh said it’s clear from the national survey results that most STEMI systems around the country are doing a lot of the important things right.
For example, 92% of systems activate the cath lab with a single phone call, 97% of PCI hospitals accept a STEMI patient 24/7 regardless of bed availability, and 84% of programs operate a data registry with continuous audit. Two-thirds of STEMI systems have the capability to transmit ECGs from at least some of their ambulances (Circ. Cardiovasc. Qual. Outcomes 2012;5:423-8).
In 87% of the networks nationwide, an emergency department physician can activate the cath lab without cardiology consultation. However, the Mayo Clinic network takes a different approach: Transferred patients bypass the emergency department and are taken straight to the coronary care unit or cath lab, according to Dr. Gersh.
In an editorial accompanying the Mission: Lifeline survey report, Dr. Timothy D. Henry, who in 2002 helped organize the nation’s first regional STEMI system at the Minneapolis Heart Institute, said, "The growth of regional STEMI systems in the United States over the past decade has clearly exceeded our expectations."
"Seven years ago," he added, "we published an article raising the question whether it was time for a national policy concerning the treatment of STEMI patients. Today, we are no closer to that policy, but I am no longer certain it is either necessary or if it would be helpful. Certainly, state and national legislation to support our financially strapped EMS would be welcome, including a 12-lead ECG in each ambulance, [an] automated external defibrillator in all public places, and support for both EMS training and data collection, as well. Public policy changes to provide financial incentives for more rational use of resources to support regional STEMI systems rather than building more catheterization laboratories would also be helpful" (Circulation 2012;126:166-8).