title: Pre-hospital acute coronary syndrome care in Kerala, India: A qualitative analysis.
abstract: OBJECTIVE
  Ischemic heart disease is the leading cause of death in India. Many of these deaths are due to acute coronary syndromes (ACS), which require prompt symptom recognition, care-seeking behavior, and transport to a treatment facility in the critical pre-hospital period. In India, little is known about pre-hospital management of individuals with ACS. We aim to understand the facilitators, barriers, and context of optimal pre-hospital ACS care to provide opportunities to reduce pre-hospital delays and improve acute cardiovascular care.
  
  
  RESULTS
  We conducted a qualitative study using in-depth interviews and focus group discussions with 27 ACS providers in Kerala, India to understand facilitators, barriers, and context to pre-hospital ACS care. Six themes emerged from these interviews and discussions: (1) individuals with ACS misperceive their symptoms as non-cardiac in origin; (2) emergency medical services are infrequently used; (3) insufficient pre-hospital healthcare infrastructure contributes to pre-hospital delay; (4) multiple stops are made before arriving at a facility that can provide definitive diagnosis and treatment; (5) relatively high costs of treatment and lack of widespread health insurance coverage limits care delivery; and (6) novel mobile technologies may allow for faster diagnosis and initiation of treatment in the pre-hospital setting.
  
  
  CONCLUSIONS
  Individualized patient-based factors (general knowledge of ACS symptoms, socioeconomic position) and broader systems-based factors (ambulance networks, coordination of transport) affect pre-hospital ACS care in Kerala. Improving public awareness of ACS symptoms, increasing appropriate use of emergency medical services, and building a infrastructure for rapid and coordinated transport may improve pre-hospital ACS care.
authors.affiliation: Departments of Preventive Medicine and Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA. Electronic address: amishapa@gmail.com.
authors.forename: Amisha
authors.initials: A
authors.lastname: Patel
authors.affiliation: Westfort Hi-Tech Hospital, Thrissur, India.
authors.forename: P P
authors.initials: PP
authors.lastname: Mohanan
authors.affiliation: Centre for Chronic Disease Control and Public Health Foundation of India, Gurgaon, NCR, India.
authors.forename: Dorairaj
authors.initials: D
authors.lastname: Prabhakaran
authors.affiliation: Departments of Preventive Medicine and Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Huffman
mesh_terms: D054058:Acute Coronary Syndrome / Q000453:epidemiology / Q000628:therapy*; D019468:Disease Management; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D006801:Humans; D015994:Incidence; D007194:India / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011785:Quality Assurance, Health Care / Q000379:methods*; D012042:Registries; D015996:Survival Rate / Q000639:trends; D013997:Time Factors
keywords: Acute coronary syndromes; Healthcare infrastructure; Pre-hospital care; Qualitative methods