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Patient and hospital determinants of primary percutaneous coronary intervention in England, 2003–2013
  1. M Hall1,
  2. K Laut1,
  3. T B Dondo1,
  4. O A Alabas1,
  5. R A Brogan1,2,
  6. N Gutacker3,
  7. R Cookson3,
  8. P Norman4,
  9. A Timmis5,
  10. M de Belder6,
  11. P F Ludman7,
  12. C P Gale1,2
  13. on behalf of the National Institute for Cardiovascular Outcomes Research (NICOR)8
  1. 1Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
  2. 2York Teaching Hospital NHS Foundation Trust, York, UK
  3. 3Centre for Health Economics, University of York, York, UK
  4. 4School of Geography, University of Leeds, Leeds, UK
  5. 5NIHR Biomedical Research Unit at Barts Health, Queen Mary University, London, UK
  6. 6The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
  7. 7Queen Elizabeth Hospital, Birmingham, UK
  8. 8National Institute for cardiovascular Outcomes Research (NICOR), University College, Institute of Cardiovascular Science, London, UK
  1. Correspondence to Dr Marlous Hall, Senior Epidemiologist, Leeds Institute of Cardiovascular and Metabolic Medicine, MRC Bioinformatics Unit, Worsley Building, Level 11, Clarendon Way, University of Leeds, Leeds LS2 9JT, UK; m.s.hall{at}leeds.ac.uk

Abstract

Objective 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.

Methods 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.

Results 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.

Conclusions 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.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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