title: Effectiveness of regionalized systems for stroke and myocardial infarction.
abstract: BACKGROUND
  Acute ischemic stroke (AIS) and ST-segment elevation myocardial infarction (STEMI) are ischemic emergencies. Guidelines recommend care delivery within formally regionalized systems of care at designated centers, with bypass of nearby centers of lesser or no designation. We review the evidence of the effectiveness of regionalized systems in AIS and STEMI.
  
  
  METHODS
  Literature was searched using terms corresponding to designation of AIS and STEMI systems and from 2010 to the present. Inclusion criteria included report of an outcome on any dependent variable mentioned in the rationale for regionalization in the guidelines and an independent variable comparing care to a non- or pre-regionalized system. Designation was defined in the AIS case as certification by the Joint Commission as either a primary (PSC) or comprehensive (CSC) stroke center. In the STEMI case, the search was conducted linking "regionalization" and "myocardial infarction" or citation as a model system by any American Heart Association statement.
  
  
  RESULTS
  For AIS, 17 publications met these criteria and were selected for review. In the STEMI case, four publications met these criteria; the search was therefore expanded by relaxing the criteria to include any historical or anecdotal comparison to a pre- or nonregionalized state. The final yield was nine papers from six systems.
  
  
  CONCLUSIONS
  Although regionalized care results in enhanced process and reduced unadjusted rates of disparity in access and adverse outcomes, these differences tend to become nonsignificant when adjusted for delayed presentation and hospital arrival by means other than emergency medical services. The benefits of regionalized care occur along with a temporal trend of improvement due to uptake of quality initiatives and guideline recommendations by all systems regardless of designation. Further research is justified with a randomized registry or cluster randomized design to support or refute recommendations that regionalization should be the standard of care.
authors.affiliation: School of Nursing University of Alabama at Birmingham Alabama.
authors.forename: James P
authors.identifier: 0000-0001-6645-7626
authors.initials: JP
authors.lastname: Rhudy
authors.affiliation: School of Nursing University of Alabama at Birmingham Alabama.
authors.forename: Marie A
authors.initials: MA
authors.lastname: Bakitas
authors.affiliation: Center for Nursing Research and Quality Outcomes Maine Medical Center Birmingham Alabama.
authors.forename: Kristiina
authors.initials: K
authors.lastname: Hyrkäs
authors.affiliation: School of Nursing University of Alabama at Birmingham Alabama.
authors.forename: Rita A
authors.initials: RA
authors.lastname: Jablonski-Jaudon
authors.affiliation: School of Nursing University of Alabama at Birmingham Alabama.
authors.forename: Erica R
authors.initials: ER
authors.lastname: Pryor
authors.affiliation: Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama.
authors.forename: Henry E
authors.initials: HE
authors.lastname: Wang
authors.affiliation: College of Nursing University of Tennessee Health Sciences Center Memphis Tennessee.
authors.forename: Anne W
authors.initials: AW
authors.lastname: Alexandrov
mesh_terms: D004635:Emergency Medicine / Q000458:organization & administration*; D006801:Humans; D009203:Myocardial Infarction / Q000628:therapy*; D020521:Stroke / Q000628:therapy*; D016896:Treatment Outcome; D014481:United States
keywords: Acute ischemic stroke; ST‐segment elevation myocardial infarction; effectiveness; outcomes