Utilization of EMS Transport Among Patients with STEMI Findings from the National Cardiovascular Data ACTION Registry–Get With The Guidelines Robin Mathews, Eric Peterson, Shuang Li, Matthew Roe, Stephen Wiviott, Jorge Saucedo, Elliott Antman, Tracy Wang

STEMI: Time is Muscle

ACC/AHA Guidelines for STEMI Care Early evaluation (e.g., pre-hospital ECG) Pre-hospital stabilization Expedited triage by receiving hospital Antman, EM, 2004 JACC (45); NRMI data (1990s) showed only 50% EMS use Canto, JG Circulation (106):

Gaps in the Data n What are contemporary patterns of EMS vs. self transport use among STEMI patients? n What are the barriers to EMS utilization? n Does EMS use improve timeliness of subsequent treatment?

ACTION Registry®-GWTG™ STEMI population Jan 01, 2007-SEP 30, 2009 Missing mode of transport Transfer- in patients Missing home zip code information Study Population 18,069 patients, 296 hospitals Self Transport 6,988 patients 38.7 % EMS Transport 11,081 patients 61.3 %

*Other variables in this model: dyslipidemia, diabetes mellitus, prior HF, HTN, atrial fibrillation/atrial flutter, prior MI, prior stroke, BMI, heart rate, dialysis, educational level, income level, race, time of presentation, rural vs. urban location Sociodemographic Factors Associated with EMS-Transport

Clinical Factors Associated with EMS-Transport

EMS Transport Reduces Symptom Onset to Hospital Arrival Time Regardless of Distance Traveled < 4 miles4-10 miles>10 miles P-value < EMS Self Time (min)

Treatment Differences Between EMS- and Self-Transport Adjusted OR (95%CI) Sx onset to arrival ≤ 120 min Time to ECG ≤ 10 min D2B ≤ 90 min 0.55 ( ) 0.52 ( ) 0.43 ( ) 31 min 3 min 13 min P<0.001 for all

Limitations n Income and educational levels derived from home zip code and census data. n Distance traveled derived from home to hospital zip code and only approximates the travel distance for an individual patient n ACTION-GWTG did not capture symptom severity n.

Conclusions n EMS continues to be underutilized among STEMI patients in contemporary practice n Estimates of socioeconomic factors, such as household income and insurance status, did not predict EMS utilization n Patients who use EMS have significantly shorter delays to presentation and treatment, even among patients who live close to the hospital

Implications n EMS use, by reducing the delay from symptom onset to hospital arrival alone, is associated with a >30 minute reduction in ischemic time n More work is needed to promote EMS use as emphasized by Mission Lifeline’s ‘chain of survival’ n Community education efforts should be tailored to groups that underutilize EMS and integrated with system-wide strategies to promote the timely use of reperfusion