A System of Care for Patients With ST-Segment Elevation Myocardial Infarction in India
Authors: Thomas Alexander, Ajit S. Mullasari, George Joseph, Kumaresan Kannan, Ganesh Veerasekar, Suma M. Victor, Colby Ayers, Viji Samuel Thomson, Vijayakumar Subban, Justin Paul Gnanaraj, Jagat Narula, Dharam J. Kumbhani, Brahmajee K. Nallamothu
Journal: JAMA Cardiology (2017)

<h3>Importance</h3> Challenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors. <h3>Objective</h3> To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model. <h3>Design, Setting, and Participants</h3> 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. <h3>Exposures</h3> 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 technology <h3>Main Outcomes and Measures</h3> 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. <h3>Results</h3> A total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [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 data were 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%];<i>P</i> = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%];<i>P</i> &lt; .001) and PCI (265 [29.5%] vs 707 [46.5%];<i>P</i> &lt; .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%];<i>P</i> = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%];<i>P</i> = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98;<i>P</i> = .04). <h3>Conclusions and Relevance</h3> A hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.