Circulation: EMS transport to PCI center more cost effective, safer for STEMI

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Transporting heart attack patients directly to PCI centers via emergency medical services (EMS) may be more effective than expanding PCI capacity at hospitals, according to a study published July 27 in Circulation: Cardiovascular Quality and Outcomes.

While the authors wrote that PCI is more effective than fibrinolytic therapy to treat STEMI patients, a majority of U.S. hospitals are not equipped to perform PCI.

To evaluate revascularization strategies for STEMI patients, Thomas W. Concannon, PhD, of the Tufts Medical Center and Tufts University School of Medicine in Boston, and colleagues estimated the costs and effectiveness of hospital-based strategies to increase PCI capacity and EMS strategies where STEMI patients are directly transported to PCI-capable hospitals.

To compare emergency resources and transportation procedures, the researchers evaluated 13 scenarios where PCI capabilities were increased and one scenario where EMS was used to transport STEMI patients to PCI-capable hospitals.

The researchers simulated EMS transport, reperfusion strategy, clinical outcomes and costs for 2,000 cases of STEMI patients in Dallas County, Texas.

Patient sample data were taken from the Atlantic Cardiovascular Patient Outcomes Research Team trial that compared PCI and fibrinolytic therapy in 451 patients with STEMI between July 1996 and June 1999. The researchers used a PCI-thrombolytic predictive instrument to predict 30-day mortality in patients.

Concannon and colleagues found that 609 PCI procedures that represented 30.4 percent of STEMI patients were performed throughout the 14 hospitals annually. Overall, the researchers found that the EMS transportation to PCI hospitals was twice as effective and 20 times less costly than expanding PCI capacity at hospitals.

Construction of a part-time lab in a hospital that sees 200 or more patients would result in an additional 82 patients who received access to PCI, but resulted in a $4.8 million increase in costs over a 10-year span. But this scenario did save 157.4 quality-adjusted life years (QALYs), at a cost of $30,399 per QALY.

The researchers found that if this same hospital had expanded the lab and provided a full-staff, 272 additional PCI procedures would have been performed and the cost per QALY would have dropped to $14,765.

Concannon and colleagues estimated that the need for an on-site CABG back-up in the PCI lab would increase cost per QALYs to $85,032 for part-time scenarios and to $31,021 for full-time. Building a new lab was most cost effective if it was opened full time and if CABG back-up program was not needed.

The scenario that expanded the PCI capabilities at the two highest volume hospitals already having PCI capabilities was most cost effective and saved $10,000 cost per QALYs and enabled 304 additional PCI interventions to be performed. Additional costs of the expansion went solely to the costs associated for the additional hiring of night and weekend staff.

The researchers estimated that the incremental costs to perform EMS transport were an additional $1,000 per diverted patient. For the 2,000 patient experimental samples, an estimated 1,391 diversions occurred at a cost of almost $1.4 million and a cost per QALY saved of $506.

“To increase access to PCI in our model of a large urban, suburban, and rural region, an EMS strategy of transporting all patients to existing PCI-capable hospitals was more effective and less costly than 13 hospital-based strategies of new construction and staffing,” the authors wrote.

“Our results strongly suggest that construction and staffing of new PCI hospitals may not be warranted if an EMS strategy is both available and feasible," wrote Concannon and colleagues, adding that expanding the access to PCI care is “critical” to improve clinical care for STEMI patients.

According to the researchers, limitations of the study stemmed from the fact that the study was speculative and used estimations and simulated scenarios.

“Our results suggest that regional planners should consider EMS strategies for increasing access to PCI before adopting strategies involving new construction or increased staffing of PCI hospitals,” the authors concluded.