Direct emergency medical services transport in STEMI: breaking the bank for non-PCI capable hospitals?

Correspondence to Dr Jacqueline L Green; [email protected] Direct emergency medical services (EMS) transport of patients with ST-elevation myocardial infarction (STEMI) to a percutaneous coronary intervention (PCI)-capable hospital is emerging as an effective strategy to improve care and reduce costs. This approach has been shown to improve mortality, decrease time to reperfusion, and reduce overall costs. Accordingly, the 2013 updated American Heart Association/ American College of Cardiology (AHA/ ACC) Guidelines for STEMI management now include a class I recommendation for direct EMS transport to a PCI-capable hospital for patients with STEMI, and EMS systems of care are maturing to facilitate this approach. Despite these important trends, however, some communities remain reluctant to implement direct EMS transport for various reasons. The study by Pathak et al published in Open Heart provides critical insight into one of the most frequently-cited concerns raised by skeptics: revenue loss at non-PCI capable hospitals as lucrative cardiovascular services are diverted away. Opponents to direct EMS transport have long perceived the practice will financially jeopardise smaller hospitals in rural and underserved communities given the large role cardiovascular services play in subsidising less reimbursed care. Pathak et al respond to this assertion with an interesting analysis of Florida’s hospital discharge data from 2006. The Florida Agency for Health Care Administration includes all discharge claims from 100% of Florida hospitals due to statewide mandatory reporting. The authors defined hospitals susceptible to losing patients through direct EMS transport as STEMI referral hospitals. These were facilities that did not perform PCI procedures on inpatients or those that performed fewer than 200 PCIs annually. By dividing all adjusted charges for patients with a primary discharge diagnosis of STEMI (using International Classification of Diseases-9 diagnostic codes) by all adjusted charges for all hospital inpatients, the authors created a metric of projected revenue loss—assuming all inpatient revenue from patients with STEMI would be lost if direct EMS transport had been instituted universally across the state. Several findings reported by the authors are noteworthy. In the primary analysis, average projected revenue losses from cardiovascular services at most STEMI referral hospitals were estimated to be minimal. Indeed, on average STEMI referral hospitals in the state had projected revenue losses of just $0.33 for every $100 of total patient revenue. Furthermore, the five hospitals with the greatest projected revenue losses from proposed direct EMS transport were all located in metropolitan areas with a high-volume PCI centre within 30 min driving distance. Only 9% of STEMI referral hospitals were rural and a mere 5% offered PCI. These findings challenge the assumption that small, rural hospitals in underserved communities will suffer by participating in a regionalised STEMI system of care that encourages direct EMS transport. Yet the primary analysis did not incorporate patients with non-STEMI with acute coronary syndrome (ACS), who also may impact the economics of STEMI referral hospitals. To address this concern, Pathak et al performed a sensitivity analysis focused on a ‘worst-case’ scenario where STEMI referral hospitals lost revenue from all patients with ACS. Even here they found negligible (<2%) losses in revenue, suggesting these facilities should expect little financial impact if they participate in a regionalised STEMI system of care that supports direct EMS transport and should be able to continue to provide essential services in other clinical areas.