A System of Care for Patients With ST-Segment Elevation Myocardial Infarction in India The Tamil Nadu-ST-Segment Elevation Myocardial Infarction Program
A System of Care for Patients With ST-Segment Elevation Myocardial Infarction in India The Tamil Nadu-ST-Segment Elevation Myocardial Infarction Program
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DOI：
10.1001/jamacardio.2016.5977
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发表时间：
2017-05-01
期刊：
影响因子：
24
通讯作者：
Nallamothu, Brahmajee K.
中科院分区：
文献类型：
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作者：
Alexander, Thomas;Mullasari, Ajit S.;Nallamothu, Brahmajee K.
重要性 由于多种系统层面的因素，改善 ST 段抬高型心肌梗死 (STEMI) 护理在中低收入国家面临着巨大的挑战。 目的 使用轮辐模型检查 STEMI 期间再灌注和经皮冠状动脉介入治疗 (PCI) 的获得情况。 设计、设置和参与者 这项质量改进计划的多中心、前瞻性、观察性研究对 2420 名 20 岁或以上的患者进行了研究。在印度南部泰米尔纳德邦的初级保健诊所、小型医院和 PCI 医院出现与 STEMI 相符的症状或体征。数据是在计划实施前从 4 个集群收集的（实施前数据）。我们需要至少 12 周的时间来获取实施前数据，期间从 2012 年 8 月 7 日一直延伸到 2013 年 1 月 5 日。然后，该计划在 4 个集群中按顺序实施，并以相同的方式收集数据（实施后数据），从 2013 年 6 月 12 日到 2014 年 6 月 24 日，平均 32 周。质量改进计划，将 35 个辐射医疗保健中心与 4 家大型 PCI 中心医院连接起来，并利用公共健康保险计划、紧急医疗服务和健康信息技术的最新发展。 主要成果和措施 主要成果集中于接受再灌注、及时再灌注、纤溶后血管造影和 PCI 的患者比例。次要结局是院内死亡率和 1 年死亡率。 结果 共纳入 2420 名 STEMI 患者（2034 名男性 [84.0%] 和 386 名女性 [16.0%]；平均 [SD] 年龄，54.7 [12.2] 岁）（实施前阶段 898 名，实施后阶段 1522 名），共有 1053 名患者(43.5%) 来自辐射医疗保健中心。收缩压 (213 [8.8%])、心率 (223 [9.2%]) 和前部 MI 位置 (279 [11.5%]) 的数据缺失很常见。总体再灌注使用和再灌注时间相似（795 [88.5%] vs 1372 [90.1%]；P = .21）。冠状动脉造影（314 [35.0%] vs 925 [60.8%]；P < .001）和 PCI（265 [29.5%] vs 707 [46.5%]；P
IMPORTANCE Challenges to improving ST-segment elevationmyocardial infarction (STEMI) care are formidable in low-to middle-income countries because of several system-level factors.OBJECTIVE To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model.DESIGN, SETTING, AND PARTICIPANTS This multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period.EXPOSURES Creation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technologyMAIN OUTCOMES AND MEASURES Primary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality.RESULTS A total of 2420 patients with STEMI (2034 men [84.0%] and 386women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing datawere common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P