US Growth in PCI Care—Less than Ideal, but is the Ideal Less?

A n ideal healthcare system aims to provide care that is safe, effective, efficient, equitable, timely and patientcentered. Translation of these aims into practice for patients suffering from ST-elevation myocardial infarction (STEMI) could result in an ideal primary percutaneous coronary intervention (PCI) system of care. In this ideal PCI system of care, PCI centers would be equitably distributed for the population at risk to ensure timely access to primary PCI. Further, PCI centers would care for an adequately sized patient population to achieve minimal volume thresholds, and to provide the procedure safely while ensuring efficient use of healthcare resources. Although an ideal PCI system of care is easy to envision, it is possible that the current primary PCI system of care in the US is not ideally configured. It would appear that an ideal PCI system of care could be designed in 1 of 2 ways to achieve high-quality care. The first approach involves integrated PCI networks that coordinate care among emergency medical services (EMS), non-PCIcapable hospitals, and PCI-capable centers through the use of established processes to ensure timely transfer of STEMI patients to PCI-capable centers. An established network may increase access to primary PCI, minimize delays in care, and optimize patient outcomes. An example of this approach is the American Heart Association’s Mission: Lifeline that seeks to improve the healthcare system’s timely response to patients with STEMI through the creation and improvement of STEMI systems of care. Another example comes from Denmark, where the development of a STEMI network has optimized patient access to PCI care for the entire country. As shown in the Figure, through coordination of EMS systems and PCI-capable centers, nearly all patients in Denmark have access to primary PCI within 120 minutes of EMS contact (red circles represent <120 minutes by helicopter EMS transport; yellow circles represent <120 minutes by ground EMS transport). A second approach to increasing PCI access is the development of new PCI-capable centers. Growth in PCIcapable hospitals would not be haphazard in an ideal PCI system of care. Instead, new PCI-capable centers would address gaps in current access to timely PCI for STEMI patients by using disease prevalence and geospatial analyses to determine new sites for PCI hospitals. In this approach, geographic regions with a high-risk patient population for STEMI and without a nearby PCI capable center would be ideal locations for new growth in PCI-capable hospitals. The study by Langabeer et al in this issue of JAHA sought to determine if growth in PCI-capable centers was consistent with this approach. The importance of this question is highlighted by the dramatic growth in PCI-capable hospitals over the past decade in the US. Using geospatial analyses, Langabeer et al modeled the temporal growth and access to primary PCI relative to the population density and MI prevalence at the state level. From 2003 to 2011, the authors determined that the number of PCI-capable hospitals in the US has grown 12.9% from 1750 to 1975 PCI centers. This growth is faster than the population growth (8.3%) and occurred during a period of declining coronary disease prevalence. Furthermore, growth in PCIcapable centers has not been uniform in relation to MI prevalence and distance between PCI facilities. For example, although the annual MI prevalence in Nevada is higher than the median (51 MIs per 1000 persons), the number of PCI facilities in the state is lower than the median (6.8 facilities per 1 million persons) with very long distances between patients and facilities (16.3 PCI facilities per 100 000 square miles). In contrast, the MI prevalence in the District of Columbia is lower than any state (21 MIs per 1000 persons), and yet the number of facilities is high (8.3 per 1 million persons) with a dramatic geographic concentration of PCI facilities (7316.4 PCI facilities per 100 000 square miles). There are clearly limitations to this type of descriptive analysis given the potential care of patients across state lines when The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the VA Eastern Colorado Health Care System, Denver, CO (S.M.B., E.P.C., P.M.H.); University of Colorado School of Medicine, Aurora, CO (S.M.B., E.P.C., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver, CO (S.M.B., P.M.H.). Correspondence to: Steven M. Bradley, MD, MPH, VA Eastern Colorado Health Care System, 1055 Clermont St (111B), Denver, CO 80220-3808. E-mail: [email protected] J Am Heart Assoc. 2013;2:e000552 doi: 10.1161/JAHA.113.000552. a 2013 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.