Clinical trials report
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Implementation of a Statewide System for Coronary Reperfusion for STEMI Jollis JG, Roettig ML, Aluko AO, et al.: Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. JAMA 2007, 298:2371–2380. Rating: •Of importance. Introduction: Reperfusion therapy for acute ST-elevation myocardial infarction (STEMI) has been proven to be the most efficacious form of treatment, with demonstrated ability to save lives and prevent or lessen long-term myocardial damage. Despite much evidence of its efficacy, reperfusion therapy is still not performed, or it is not performed optimally, in many clinical settings. This is often due to the lack of coordinated systems of care for STEMI patients. Aims: This study investigated whether the establishment of a statewide system of reperfusion therapy for STEMI patients in North Carolina would overcome barriers, increase the frequency of use, and reduce time delays for reperfusion therapy. Reperfusion therapy was considered to be fibrinolytic therapy or primary percutaneous coronary intervention (PPCI)—whichever was most appropriate to the specific setting. Methods: The state of North Carolina was divided into five regions. Each region had at least one central PPCIcapable hospital and several peripheral, community-based hospitals not equipped for PPCI. Within each region the participating hospitals formed networks and agreed to common goals and guidelines. A statewide implementation program lasting 1 year was undertaken to bring the five regions into coordinated action as specified. The implementation program involved all aspects of the reperfusion process: emergency medical services (EMS), emergency departments, cardiac catheterization laboratories, and interhospital transfer systems. The main outcome measures were prespecified as reperfusion times and reperfusion rates (frequencies). The outcome measures were compared between a 3-month period prior to program implementation (July–September 2005) and a 3-month period after the year-long implementation (January–March 2007). Results: At non–PCI-capable community hospitals, where most STEMI patients initially presented (925/1427; 65%), the initial form of therapy changed only slightly. Prior to the program, 40% of the STEMI patients were
transferred immediately, while 45% received an initial dose of fibrinolytics. After the program was in operation, 46% were transferred immediately and 39% received an initial dose of fibrinolytics. Nevertheless, in both periods virtually all of the STEMI patients ultimately were transferred to a PCI-capable hospital (92% and 95%), making a decision on the initial form of therapy less critical. Importantly, well over half (57%) of STEMI patients presenting at hospitals without PCI capability came by self-transport or via relatives or friends. At PCIcapable hospitals, the proportion of STEMI patients treated with PPCI (via direct presentation and transfers) increased from 47.5% before the program started to 63% afterward (P < 0.001). Overall, the proportion o
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