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VIEWPOINT AND COMMENTARY

Regionalization of ST-Segment Elevation Acute Coronary Syndromes Care

Putting a National Policy in Proper Perspective

Saif S. Rathore, MPH^_*, Andrew J. Epstein, PhD, MPP, Brahmajee K. Nallamothu, MD, MPH^|| and Harlan M. Krumholz, MD, SM^_*,,,,_*

^_* Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, Connecticut
^|| Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, Michigan

Manuscript received September 9, 2005; revised manuscript received November 6, 2005, accepted November 8, 2005.

^_* Address correspondence to: Dr. Harlan M. Krumholz, Yale University School of Medicine, Internal Medicine, PO Box 208088, 333 Cedar Street, New Haven, Connecticut 06520. (Email: harlan.krumholz{at}yale.edu).

A uniform policy for regionalization of ST-segment elevation myocardial infarction (STEMI) care raises several concerns. Transferring all STEMI patients to obtain primary percutaneous coronary intervention (PCI) may be less effective than transferring only high-risk STEMI patients. Delays in time to treatment >60 min associated with transferring patients for primary PCI may result in increased mortality for the average patient as compared with providing immediate fibrinolytic therapy at their initial hospital; yet more than 95% of patients transferred for primary PCI in the U.S. exceed this 60-min benchmark. Superior outcomes associated with treatment at higher-volume regional STEMI centers are inconsistent among centers, and there is no direct evidence that patients will benefit by a transfer to a high-volume hospital from a low-volume hospital. Published data suggest as many as 800 PCI patients would need to be transferred to a high-volume PCI hospital to avoid a single death at a low-volume PCI hospital. Although European randomized trial data suggest transferring patients with STEMI for primary PCI may be superior to immediate fibrinolytic therapy, these findings are unlikely to generalize to the U.S. health care system given size, geography, and organization. ST segment elevation myocardial infarction care regionalization would require a massive redistribution of health care resources, depriving several hospitals of advanced cardiac care facilities, expertise, and associated revenue. Clearer evidence of the benefits and discussion of potential harms are needed before adopting a national STEMI regionalization policy.

Abbreviations and Acronyms   ACS = acute coronary syndromes   EMS = emergency medical services   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction

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