Feature: Unite! CV emergency care system across the U.S. may be in order

In 2007, nearly four million emergency department visits in the U.S. were linked to cardiovascular disease. As medical costs for cardiovascular disease (CVD) are set to triple by 2030 to $800 billion, the U.S. must find a way to simultaneously become more cost-effective and efficient, and employing a national cardiovascular emergency care system could be the answer.

The report, published in the April 24 issue of Circulation, looked at the feasibility, need and the possible financial profits of deploying these types of regional systems, using Minneapolis Heart Institute's (MHI) regional systems of care for various CV emergencies as a model.

“The current system for care for cardiovascular emergencies is fragmented across the country and even within Minneapolis is relatively fragmented,” the study's co-author Craig E. Strauss, MD, MPH, a cardiologist at MHI and physician researcher with the MHI Foundation, told Cardiovascular Business.

“The coordination of care varies in the U.S. depending on where a patient presents," he said, with facilities as varied as critical access hospitals, unaffiliated emergency services, transport services and tertiary hospitals.

Strauss said that according to the American Heart Association’s Mission Lifeline initiative, only 25 percent of U.S. hospitals are capable of performing PCI. Efficient transport for these patients is important, particularly to ensure that guideline-driven initiatives like door-to-balloon times of 90 minutes or less are being met.  

“It’s really about coordinating the care across the different entities from the first responders to the referral hospitals and to the PCI-capable center for STEMI patients in particular,” Strauss added.

Over the past 10 years, MHI at Abbott Northwestern Hospital (MHI-ANH) has deployed regional systems of care throughout its network of 50 community hospitals and clinics and 75 emergency medical services (EMS) agencies within a 500-mile radius for STEMI, out-of-hospital cardiac arrest, acute aortic dissection, abdominal aortic aneurysm, stroke and acute decompensated heart failure/cardiogenic shock. MHI-ANH now serves as a successful model for what the framework for instating one of these cardiovascular emergency systems nationwide should look like. 

Strauss offered that the key to a successful CV emergency care system is first developing a collaborative group of participants. That would require three main stakeholders on board: EMS, referral hospitals and tertiary hospitals, he said. “You must first recognize that each of these participants plays an extremely important role to getting the patients the best and most efficient care.

“You must recognize the opportunities within the initiate diagnosis,” Strauss said. This means to pinpoint every opportunity for pre-hospital activation of the cath lab and the performance of initial EKGs in the ambulance to get the patient’s care started sooner, rather than later.

Currently, Strauss said the U.S. healthcare system is set up to transfer patients to the closest hospitals. “This can lead to multiple transfers and multiple inefficiencies within the system due to the fact that some hospitals are not PCI-capable and may not be staffed to perform a certain procedure, like aortic dissection,” he said. Strauss said that recognizing everyone’s role in the system is an important first step.

While Strauss offered that there will be challenges to setting one of these systems up because of the “complex and cumbersome nature of the healthcare system,” he said that benefits may include opportunities to reduce costs and inefficiencies.

In a previous single-center study, Khot et al found that implementing a STEMI system resulted in a cost savings of $10,000 per patient for the index event and an additional $4,000 in savings for subsequent medical care during the first year post-hospital discharge (BMC Cardiovasc Disord 2009;9:32).

Due to the current payment model though, Strauss said that there may be barriers to implementation because there are different organizations with different goals. He noted that access to resources could be one of these hurdles.

“These are different healthcare organizations that have different strategies and goals. When bringing all participants together, it can be challenging to get everyone on the same page, to share the same goals, get the best outcomes and provide patients with the best definitive treatment," Strauss offered. "It requires a lot of working together and collaboration."

“This will become about bringing the fragmented pieces of our system together and sharing responsibility to provide the optimal care to the patient in a seamless fashion between the otherwise disparate organizations,” Strauss summed. “There is a lot of value from doing this from an outcomes standpoint and a fiscal responsibility standpoint. And there is tremendous potential in the world of cardiovascular emergencies to implement these across the country and bring together the appropriate stakeholders to make that a reality that can hopefully provide improved outcomes over the next several years.”