A system of care for patients with ST-segment elevation myocardial infarction in India: The Tamil Nadu-ST-segment elevation myocardial infarction program

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

Research output: Contribution to journalArticle

30 Citations (Scopus)

Abstract

Importance: Challenges to improving ST-segment elevationmyocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors. Objective: To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model. Design, Setting, and Participants: 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. Exposures: 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 Main Outcomes and Measures: 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. Results: 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 datawere 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%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001)were more commonly performed during the postimplementation phase. In-hospital mortalitywas not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortalitywas lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95%CI, 0.58-0.98; P = .04). Conclusions and Relevance: 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.

Original languageEnglish (US)
Pages (from-to)498-505
Number of pages8
JournalJAMA Cardiology
Volume2
Issue number5
DOIs
StatePublished - May 1 2017

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Percutaneous Coronary Intervention
Infarction
India
Patient Care
Reperfusion
Quality Improvement
Blood Pressure
Delivery of Health Care
Medical Informatics
Mortality
Emergency Medical Services
Health Insurance
Coronary Angiography
Signs and Symptoms
Observational Studies
ST Elevation Myocardial Infarction
Primary Health Care
Angiography
Public Health
Heart Rate

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

A system of care for patients with ST-segment elevation myocardial infarction in India : The Tamil Nadu-ST-segment elevation myocardial infarction program. / Alexander, Thomas; Mullasari, Ajit S.; Joseph, George; Kannan, Kumaresan; Veerasekar, Ganesh; Victor, Suma M.; Ayers, Colby; Thomson, Viji Samuel; Subban, Vijayakumar; Gnanaraj, Justin Paul; Narula, Jagat; Kumbhani, Dharam J.; Nallamothu, Brahmajee K.

In: JAMA Cardiology, Vol. 2, No. 5, 01.05.2017, p. 498-505.

Research output: Contribution to journalArticle

Alexander, T, Mullasari, AS, Joseph, G, Kannan, K, Veerasekar, G, Victor, SM, Ayers, C, Thomson, VS, Subban, V, Gnanaraj, JP, Narula, J, Kumbhani, DJ & Nallamothu, BK 2017, 'A system of care for patients with ST-segment elevation myocardial infarction in India: The Tamil Nadu-ST-segment elevation myocardial infarction program', JAMA Cardiology, vol. 2, no. 5, pp. 498-505. https://doi.org/10.1001/jamacardio.2016.5977
Alexander, Thomas ; Mullasari, Ajit S. ; Joseph, George ; Kannan, Kumaresan ; Veerasekar, Ganesh ; Victor, Suma M. ; Ayers, Colby ; Thomson, Viji Samuel ; Subban, Vijayakumar ; Gnanaraj, Justin Paul ; Narula, Jagat ; Kumbhani, Dharam J. ; Nallamothu, Brahmajee K. / A system of care for patients with ST-segment elevation myocardial infarction in India : The Tamil Nadu-ST-segment elevation myocardial infarction program. In: JAMA Cardiology. 2017 ; Vol. 2, No. 5. pp. 498-505.
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abstract = "Importance: Challenges to improving ST-segment elevationmyocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors. Objective: To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model. Design, Setting, and Participants: 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. Exposures: 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 Main Outcomes and Measures: 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. Results: 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 datawere 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{\%}]; P = .21). Coronary angiography (314 [35.0{\%}] vs 925 [60.8{\%}]; P < .001) and PCI (265 [29.5{\%}] vs 707 [46.5{\%}]; P < .001)were more commonly performed during the postimplementation phase. In-hospital mortalitywas not different (52 [5.8{\%}] vs 85 [5.6{\%}]; P = .83), but 1-year mortalitywas lower in the postimplementation phase (134 [17.6{\%}] vs 179 [14.2{\%}]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95{\%}CI, 0.58-0.98; P = .04). Conclusions and Relevance: 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.",
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T1 - A system of care for patients with ST-segment elevation myocardial infarction in India

T2 - The Tamil Nadu-ST-segment elevation myocardial infarction program

AU - Alexander, Thomas

AU - Mullasari, Ajit S.

AU - Joseph, George

AU - Kannan, Kumaresan

AU - Veerasekar, Ganesh

AU - Victor, Suma M.

AU - Ayers, Colby

AU - Thomson, Viji Samuel

AU - Subban, Vijayakumar

AU - Gnanaraj, Justin Paul

AU - Narula, Jagat

AU - Kumbhani, Dharam J.

AU - Nallamothu, Brahmajee K.

PY - 2017/5/1

Y1 - 2017/5/1

N2 - Importance: Challenges to improving ST-segment elevationmyocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors. Objective: To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model. Design, Setting, and Participants: 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. Exposures: 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 Main Outcomes and Measures: 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. Results: 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 datawere 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%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001)were more commonly performed during the postimplementation phase. In-hospital mortalitywas not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortalitywas lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95%CI, 0.58-0.98; P = .04). Conclusions and Relevance: 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.

AB - Importance: Challenges to improving ST-segment elevationmyocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors. Objective: To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model. Design, Setting, and Participants: 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. Exposures: 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 Main Outcomes and Measures: 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. Results: 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 datawere 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%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001)were more commonly performed during the postimplementation phase. In-hospital mortalitywas not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortalitywas lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95%CI, 0.58-0.98; P = .04). Conclusions and Relevance: 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.

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