title: Nationwide Analysis of Patients With ST-Segment-Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention: Findings From the American Heart Association Mission: Lifeline Program.
abstract: BACKGROUND
  Current American College of Cardiology/American Heart Association guidelines recommend transfer and primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) patients within the time limit of first contact to device ≤ 120 minutes. We determined the hospital-level, patient-level, and process characteristics of timely versus delayed primary PCI for a diverse national sample of transfer patients confined to a travel distance that facilitates the process.
  
  
  RESULTS
  We studied 14,518 patients transferred from non-PCI-capable hospitals for primary PCI to 398 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals between July 2008 and December 2012. Patients with estimated transfer times > 60 minutes (by Google Maps driving times) were excluded from the analysis. Patients achieving first door-to-device time ≤ 120 minutes were compared with patients with delayed treatment; independent predictors of timely treatment were determined using generalized estimating equations logistic regression models. The median estimated transfer distance was 26.5 miles. First door-to-device ≤ 120 minutes was achieved in 65% of patients (n = 9380); only 37% of the hospitals were high-performing hospitals (defined as risk-adjusted rate, ≥ 75% of transfer STEMI patients with ≤ 120-minute first door-to-device time). In addition to known predictors of delay (cardiogenic shock, cardiac arrest, and prolonged door-in door-out time), STEMI referral hospitals' rural location and longer estimated transfer time were identified as predictors of delay. In this diverse national sample, regional and racial variations in care were observed. Finally, lower PCI hospital annual STEMI volume was a potent predictor of delay.
  
  
  CONCLUSIONS
  More than one third of US STEMI patients transferred for primary PCI fail to achieve first door-to-device time ≤ 120 minutes, despite estimated transfer times <60 minutes. Delays are related to process variables, comorbidities, and lower annual PCI hospital STEMI volumes.
authors.affiliation: From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.). harold.dauerman@uvmhealth.org.
authors.forename: Harold L
authors.initials: HL
authors.lastname: Dauerman
authors.affiliation: From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.).
authors.forename: Eric R
authors.initials: ER
authors.lastname: Bates
authors.affiliation: From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.).
authors.forename: Michael C
authors.initials: MC
authors.lastname: Kontos
authors.affiliation: From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.).
authors.forename: Shuang
authors.initials: S
authors.lastname: Li
authors.affiliation: From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.).
authors.forename: J Lee
authors.initials: JL
authors.lastname: Garvey
authors.affiliation: From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.).
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Henry
authors.affiliation: From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.).
authors.forename: Steven V
authors.initials: SV
authors.lastname: Manoukian
authors.affiliation: From the University of Vermont Cardiovascular Research Institute, Burlington (H.L.D.); University of Michigan, Ann Arbor (E.R.B.); Virginia Commonwealth University, Richmond (M.C.K.); Duke Clinical Research Institute, Durham, NC (S.L., M.T.R.); Carolinas Medical Center, Charlotte, NC (J.L.G.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Hospital Corporation of America, Nashville, TN (S.V.M.).
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
mesh_terms: D000572:American Heart Association; D006297:Health Services Accessibility; D006801:Humans; D009203:Myocardial Infarction / Q000628:therapy*; D015425:Myocardial Reperfusion; D010360:Patient Transfer / Q000706:statistics & numerical data; D062645:Percutaneous Coronary Intervention; D012042:Registries; D013997:Time Factors; D061665:Time-to-Treatment; D014481:United States
keywords: ST-segment–elevation myocardial infarction; regional systems of care; transfer