title: Patient and hospital determinants of primary percutaneous coronary intervention in England, 2003-2013.
abstract: Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is insufficiently implemented in many countries. We investigated patient and hospital characteristics associated with PPCI utilisation.
  
  
  
  Whole country registry data (MINAP, Myocardial Ischaemia National Audit Project) comprising PPCI-capable National Health Service trusts in England (84 hospital trusts; 92 350 hospitalisations; 90 489 patients), 2003-2013. Multilevel Poisson regression modelled the relationship between incidence rate ratios (IRR) of PPCI and patient and trust-level factors.
  
  
  
  Overall, standardised rates of PPCI increased from 0.01% to 86.3% (2003-2013). While, on average, there was a yearly increase in PPCI utilisation of 30% (adjusted IRR 1.30, 95% CI 1.23 to 1.36), it varied substantially between trusts. PPCI rates were lower for patients with previous myocardial infarction (0.95, 0.93 to 0.98), heart failure (0.86, 0.81 to 0.92), angina (0.96, 0.94 to 0.98), diabetes (0.97, 0.95 to 0.99), chronic renal failure (0.89, 0.85 to 0.90), cerebrovascular disease (0.96, 0.93 to 0.99), age >80 years (0.87, 0.85 to 0.90), and travel distances >30 km (0.95, 0.93 to 0.98). PPCI rates were higher for patients with previous percutaneous coronary intervention (1.09, 1.05 to 1.12) and among trusts with >5 interventional cardiologists (1.30, 1.25 to 1.34), more visiting interventional cardiologists (1-5: 1.31, 1.26 to 1.36; ≥6: 1.42, 1.35 to 1.49), and a 24 h, 7-days-a-week PPCI service (2.69, 2.58 to 2.81). Half of the unexplained variation in PPCI rates was due to between-trust differences.
  
  
  
  Following an 8 year implementation phase, PPCI utilisation rates stabilised at 85%. However, older and sicker patients were less likely to receive PPCI and there remained between-trust variation in PPCI rates not attributable to differences in staffing levels. Compliance with clinical pathways for STEMI is needed to ensure more equitable quality of care.
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: M
authors.initials: M
authors.lastname: Hall
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: K
authors.initials: K
authors.lastname: Laut
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: T B
authors.initials: TB
authors.lastname: Dondo
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
authors.forename: O A
authors.initials: OA
authors.lastname: Alabas
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK York Teaching Hospital NHS Foundation Trust, York, UK.
authors.forename: R A
authors.initials: RA
authors.lastname: Brogan
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: N
authors.initials: N
authors.lastname: Gutacker
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: R
authors.initials: R
authors.lastname: Cookson
authors.affiliation: School of Geography, University of Leeds, Leeds, UK.
authors.forename: P
authors.initials: P
authors.lastname: Norman
authors.affiliation: NIHR Biomedical Research Unit at Barts Health, Queen Mary University, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Timmis
authors.affiliation: The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK.
authors.forename: M
authors.initials: M
authors.lastname: de Belder
authors.affiliation: Queen Elizabeth Hospital, Birmingham, UK.
authors.forename: P F
authors.initials: PF
authors.lastname: Ludman
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK York Teaching Hospital NHS Foundation Trust, York, UK.
authors.forename: C P
authors.initials: CP
authors.lastname: Gale