Colin J Forsyth

Transfer Travel Times for Primary Percutaneous Coronary Intervention From Low-Volume and Non–Percutaneous Coronary Intervention–Capable Hospitals to High-Volume Centers in Florida

STUDY OBJECTIVE Current guidelines recommend that ST-elevation myocardial infarction (STEMI) patients receive percutaneous coronary intervention less than or equal to 90 minutes from first medical contact, preferably at high-volume percutaneous coronary intervention centers (≥400 percutaneous coronary interventions annually). Because many patients present to low-volume or non-percutaneous coronary intervention-capable STEMI referral hospitals, timely percutaneous coronary intervention treatment requires effective transfer systems, which include interfacility transport times of less than 30 minutes. We investigate the geographic feasibility of achieving timely interfacility transport from STEMI referral hospitals to percutaneous coronary intervention hospitals in Florida. METHODS Using 2006 Florida hospital discharge data, we calculated driving times between STEMI referral hospitals and the nearest medium-/high-volume percutaneous coronary intervention centers. We plotted transfer travel time cumulative proportion survival curves for hospitals and patients to assess the feasibility of transfer within 30 minutes to higher-volume facilities. Differences by geographic location (rural versus urban) and patient race/ethnicity were examined. RESULTS In 2006, 77% of STEMI referral hospitals had transfer travel times within 30 minutes; 90th percentile for interhospital driving time was 56 minutes. For patients at STEMI referral hospitals, 85.6% were at facilities within a 30-minute drive of a high-/medium-volume percutaneous coronary intervention center; 90th percentile was 31 minutes. We found marked rural/urban disparities, with longer average driving times for patients in rural and small metropolitan counties. Significant racial/ethnic disparities in transfer travel times were not observed, although 90th percentile driving times were highest for blacks. CONCLUSION Driving times do not pose a major geographic barrier to transfer of STEMI patients in Florida. A majority of STEMI patients could be transferred from STEMI referral hospitals to high-volume percutaneous coronary intervention centers within 30 minutes.

De Facto regionalization of care for ST-elevation myocardial infarction in Florida, 2001–2009

ACC/AHA guidelines recommend STEMI patients receive percutaneous coronary intervention (PCI) at high volume hospitals performing ≥400 procedures/year. The objective of this study was to evaluate changes in the organization and implementation of care for STEMI patients in Florida. We assessed trends and predictors of STEMI patients first hospitalized at high PCI volume hospitals in Florida from 2001-2009. This is the first study to examine statewide trends in hospital admission for all STEMI patients. We classified Florida hospitals by PCI volume (high, medium, low, non-PCI) for each quarter from January, 2001 through June, 2009. Using hospital discharge data, we determined the percent of STEMI patients who went to each type of hospital and analyzed multiple predictors. From 2001-2009 the proportion of STEMI patients first hospitalized at high PCI volume hospitals rose from 62.4 to 89.7%, while admissions to non-PCI hospitals declined from 31% to 4.9%. Persistent barriers to high PCI volume hospital admission were age ≥85 years (OR 0.56, 95% CI 0.50-0.62), female gender (OR 0.85, 95% CI 0.79-0.91), and residence in a major metropolitan county. Through the efforts of local coalitions throughout Florida, by 2009 almost 90% of Florida STEMI patients were first admitted to high PCI volume hospitals. Greater hospital competition may explain lower admission rates to high PCI volume hospitals in major metropolitan counties. The age and gender disadvantage we observed requires further research to determine potential causes.

Routine diversion of patients with STEMI to high-volume PCI centres: modelling the financial impact on referral hospitals

Objective To quantify possible revenue losses from proposed ST-elevation myocardial infarction (STEMI) patient diversion policies for small hospitals that lack high-volume percutaneous coronary intervention (PCI) capability status (ie, ‘STEMI referral hospitals’). Background Negative financial impacts on STEMI referral hospitals have been discussed as an important barrier to implementing regional STEMI bypass/transfer protocols. However, there is little empirical data available that directly quantifies this potential financial impact. Methods Using detailed financial charges from Florida hospital discharge data, we examined the potential negative financial impact on 112 STEMI referral hospitals from losing all inpatient STEMI revenue. The main outcome was projected revenue loss (PRL), defined as total annual patient with STEMI charges as a proportion of total annual charges for all patients. We hypothesised that for most community hospitals (>90%), STEMI revenue represented only a small fraction of total revenue (<1%). We further examined the financial impact of the ‘worst case’ scenario of loss of all acute coronary syndrome (ACS) (ie, chest pain) patients. Results PRLs were

From Lemongrass to Ivermectin: Ethnomedical Management of Chagas Disease in Tropical Bolivia

0.33 for every

I Cannot Be Worried: Living with Chagas Disease in Tropical Bolivia

100 of patient revenue statewide for STEMI and

Controlled but not cured: Structural processes and explanatory models of Chagas disease in tropical Bolivia.

1.73 for ACS. At the individual hospital level, the 90th centile PRL was

Abstract 10: Widening Rural Disadvantage in United States Premature Heart Disease Mortality: Trends by Region and Race/Ethnicity, 2000 - 2013

0.74 for STEMI and

Structural Processes and Local Meaning: Explanatory Models, Political Economy, and Chagas Disease in Tropical Bolivia

2.77 for ACS. PRLs for STEMI were not greater in rural areas compared with major metropolitan areas. Hospital revenue centres that would be most impacted by loss of patients with STEMI were cardiology procedures and intensive care units. Conclusions Loss of patient with STEMI revenues would result in only a small financial impact on STEMI referral hospitals in Florida under proposed STEMI diversion/rapid transfer protocols. However, spillover loss of patients with ACS would increase revenue loss for many hospitals.

Abstract P321: Hospital Angioplasty Volumes and ST-Elevation Myocardial Infarction Patient Admission Patterns: Improvement in Florida from 2001-2007

ABSTRACT Chagas disease is a neglected tropical disease; the only viable drugs are outdated and produce frequent side effects, and the overwhelming majority of cases are undiagnosed and untreated. Globally, people encounter numerous impediments to accessing biomedical treatment for Chagas disease. However, little is known about how people with Chagas disease manage their health outside the biomedical system. In this article, I discuss knowledge of ethnomedical treatments among marginalized patients in an endemic area of Bolivia. I interviewed 68 patients, 63 (93 percent) of whom had positive diagnoses for Chagas disease. Participants free listed 66 ethnomedical remedies either for Chagas disease (n = 39) or its cardiac symptoms. Participants stressed the accessibility of ethnomedical remedies in contrast to the multiple barriers to accessing biomedical treatment. Far from eroding in the face of globalization and sociopolitical marginalization, ethnomedical knowledge in the study area is dynamic and flexible, communicated through various channels.

Abstract P293: Small Area Analysis of ST-Elevation Myocardial Infarction Admissions to Non- Percutaneous Coronary Intervention Hospitals in Miami-Dade County, Florida, 2007

Background Chagas disease (CD) profoundly affects the social and emotional dimensions of patients’ lives, and disproportionately impacts poor, marginalized populations in Latin America. Biomedical treatment for CD fails to reach up to 99% of the people affected, and in any case seldom addresses the emotional health or socioeconomic conditions of patients. This study examines patient strategies for coping with CD in the department of Santa Cruz, Bolivia. Methodology In this ethnographic study, semistructured interviews took place from March-June 2013 with 63 patients who had previously tested positive for CD. During the fieldwork period, participant observation was conducted and patient family members, providers, community members, and public health officials were consulted. Principal Findings Patients often experienced emotional distress when diagnosed with CD, yet were generally unable to find biomedical treatment. Respondents stressed the need to avoid powerful emotions which would worsen the impact of CD symptoms. To manage CD, patients embraced a calm state of mind, described in Spanish as tranquilidad, which partially empowered them to return to a normal existence. Conclusions In the perceived absence of biomedical treatment options, patients seek their own means of coping with CD diagnosis. Rather than fatalism or resignation, patients’ emphasis on maintaining calm and not worrying about CD represents a pragmatic strategy for restoring a sense of normalcy and control to their lives. Programs focused on treatment of CD should remain mindful of the emotional and social impact of the disease on patients.