title: A System of Care for Patients With ST-Segment Elevation Myocardial Infarction in India: The Tamil Nadu-ST-Segment Elevation Myocardial Infarction Program.
abstract: Challenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors.
  
  
  
  To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model.
  
  
  
  This multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period.
  
  
  
  Creation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology.
  
  
  
  Primary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality.
  
  
  
  A total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98; P = .04).
  
  
  
  A hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.
authors.affiliation: Department of Cardiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India.
authors.forename: Thomas
authors.initials: T
authors.lastname: Alexander
authors.affiliation: Department of Cardiology, Madras Medical Mission, Chennai, Tamil Nadu, India.
authors.forename: Ajit S
authors.initials: AS
authors.lastname: Mullasari
authors.affiliation: Department of Cardiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India.
authors.forename: George
authors.initials: G
authors.lastname: Joseph
authors.affiliation: Department of Cardiology, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India.
authors.forename: Kumaresan
authors.initials: K
authors.lastname: Kannan
authors.affiliation: Department of Clinical Epidemiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India.
authors.forename: Ganesh
authors.initials: G
authors.lastname: Veerasekar
authors.affiliation: Department of Cardiology, Madras Medical Mission, Chennai, Tamil Nadu, India.
authors.forename: Suma M
authors.initials: SM
authors.lastname: Victor
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
authors.forename: Colby
authors.initials: C
authors.lastname: Ayers
authors.affiliation: Department of Cardiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India.
authors.forename: Viji Samuel
authors.initials: VS
authors.lastname: Thomson
authors.affiliation: Department of Cardiology, Madras Medical Mission, Chennai, Tamil Nadu, India.
authors.forename: Vijayakumar
authors.initials: V
authors.lastname: Subban
authors.affiliation: Department of Cardiology, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India.
authors.forename: Justin Paul
authors.initials: JP
authors.lastname: Gnanaraj
authors.affiliation: Division of Cardiology, Icahn School of Medicine, Mount Sinai Hospital, New York, New York.
authors.forename: Jagat
authors.initials: J
authors.lastname: Narula
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
authors.forename: Dharam J
authors.initials: DJ
authors.lastname: Kumbhani
authors.affiliation: Department of Internal Medicine and Michigan Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor.
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
mesh_terms: D000328:Adult; D000368:Aged; D017023:Coronary Angiography / Q000706:statistics & numerical data*; D003906:Developing Countries; D004632:Emergency Medical Services; D005260:Female; D006297:Health Services Accessibility; D017052:Hospital Mortality; D006801:Humans; D007194:India; D007348:Insurance, Health; D008297:Male; D008490:Medical Informatics; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data*; D011446:Prospective Studies; D058996:Quality Improvement / Q000458:organization & administration*; D000072657:ST Elevation Myocardial Infarction / Q000000981:diagnostic imaging / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*; D061665:Time-to-Treatment / Q000706:statistics & numerical data*