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International Journal for Equity in Health

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Open Access 01-12-2022 | Care | Research

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

Authors: Siwen Li, Xuejie Dong, Dongmei Li, Hongjuan Zhang, Shuduo Zhou, Mailikezhati Maimaitiming, Junxiong Ma, Na Li, Qiang Zhou, Yinzi Jin, Zhi-Jie Zheng

Published in: International Journal for Equity in Health | Issue 1/2022

Abstract

Background

Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients.

Methods

This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations.

Results

There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively.

Conclusions

Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public.

Pocock SJ, Huo Y, Van de Werf F, Newsome S, Chin CT, Vega AM, et al. Predicting two-year mortality from discharge after acute coronary syndrome: an internationally-based risk score. Eur Heart J Acute Cardiovasc Care. 2019. https://doi.org/10.1177/2048872617719638.

Shen C, Ge J. Epidemic of cardiovascular disease in China: current perspective and prospects for the future. Circulation. 2018. https://doi.org/10.1161/CIRCULATIONAHA.118.033484.

Kushner FG, Hand M, Smith SC Jr, King SB 3rd, Anderson JL, Antman EM, et al. Focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2009, 2009. https://doi.org/10.1016/j.jacc.2009.10.015.

Krumholz HM, Bradley EH, Nallamothu BK, Ting HH, Batchelor WB, Kline-Rogers E, et al. A campaign to improve the timeliness of primary percutaneous coronary intervention: door-to-balloon: an Alliance for quality. JACC Cardiovasc Interv. 2008. https://doi.org/10.1016/j.jcin.2007.10.006.

De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004. https://doi.org/10.1161/01.CIR.0000121424.76486.20.

Bruins Slot MH, Rutten FH, van der Heijden GJ, Doevendans PA, Mast EG, Bredero AC, et al. Gender differences in pre-hospital time delay and symptom presentation in patients suspected of acute coronary syndrome in primary care. Fam Pract. 2012. https://doi.org/10.1093/fampra/cmr089.

Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. ACC/AHA guideline on the primary prevention of cardiovascular disease: executive summary: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2019, 2019. https://doi.org/10.1161/CIR.0000000000000677.

Goldberg RJ, Steg PG, Sadiq I, Granger CB, Jackson EA, Budaj A, et al. Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry). Am J Cardiol. 2002. https://doi.org/10.1016/s0002-9149(02)02186-0.

Jacobs AK. Regional systems of care for patients with ST-elevation myocardial infarction: being at the right place at the right time. Circulation. 2007. https://doi.org/10.1161/CIRCULATIONAHA.107.720946.

10.

McKee G, Mooney M, O'Donnell S, O'Brien F, Biddle MJ, Moser DK. Multivariate analysis of predictors of pre-hospital delay in acute coronary syndrome. Int J Cardiol. 2013. https://doi.org/10.1016/j.ijcard.2013.03.022.

11.

Timmis A, Townsend N, Gale C, Grobbee R, Maniadakis N, Flather M, et al. European Society of Cardiology: cardiovascular disease statistics 2017. Eur Heart J. 2018. https://doi.org/10.1093/eurheartj/ehx628.

12.

Dharma S, Andriantoro H, Dakota I, Purnawan I, Pratama V, Isnanijah H, et al. Organisation of reperfusion therapy for STEMI in a developing country. Open Heart. 2015;2(1):e000240. https://doi.org/10.1136/openhrt-2015-000240 PMID: 26019883; PMCID: PMC4442233.CrossRef

13.

Galappatthy P, Bataduwaarachchi VR, Ranasinghe P, Galappatthy GKS, Wijayabandara M, Warapitiya DS, et al. Management, characteristics and outcomes of patients with acute coronary syndrome in Sri Lanka. Heart. 2018. https://doi.org/10.1136/heartjnl-2017-312404.

14.

Kurz MC, Schmicker RH, Leroux B, Nichol G, Aufderheide TP, Cheskes S, et al. Advanced vs. Basic Life Support in the Treatment of Out-of-Hospital Cardiopulmonary Arrest in the Resuscitation Outcomes Consortium. Resuscitation. 2018. https://doi.org/10.1016/j.resuscitation.2018.04.031.

15.

Cournoyer A, Notebaert É, Iseppon M, Cossette S, Londei-Leduc L, Lamarche Y, et al. Prehospital advanced cardiac life support for out-of-hospital cardiac arrest: a cohort study. Acad Emerg Med. 2017. https://doi.org/10.1111/acem.13246.

16.

Chocron R, Loeb T, Lamhaut L, Jost D, Adnet F, Lecarpentier E, et al. Ambulance density and outcomes after out-of-hospital cardiac arrest. Circulation. 2019. https://doi.org/10.1161/CIRCULATIONAHA.118.035113.

17.

Dharma S. Comparison of real-life Systems of Care for ST-segment elevation myocardial infarction. Glob Heart. 2020. https://doi.org/10.5334/gh.343.

18.

Harper S, Lynch J, Meersman SC, Breen N, Davis WW, Reichman ME. An overview of methods for monitoring social disparities in cancer with an example using trends in lung cancer incidence by area-socioeconomic position and race-ethnicity, 1992-2004. Am J Epidemiol. 2008. https://doi.org/10.1093/aje/kwn016.

19.

Manz KM, Mansmann U. Inequality indices to monitor geographic differences in incidence, mortality and fatality rates over time during the COVID-19 pandemic. PLoS One. 2021. https://doi.org/10.1371/journal.pone.0251366.

20.

Lorenz MO. Methods of measuring the concentration of wealth. Publ Am Stat Assoc. 1905;9:209–19.

21.

O'Donnell O, O'Neill S, Van Ourti T, Walsh B. Conindex: estimation of concentration indices. Stata J. 2016;16:112–38.CrossRef

22.

Horev T, Pesis-Katz I, Mukamel DB. Trends in geographic disparities in allocation of health care resources in the US. Health Policy. 2004. https://doi.org/10.1016/j.healthpol.2003.09.011.

23.

Rezaei S, Karyani AK, Fallah R, Matin BK. Relative inequalities in geographic distribution of health care resources in Kermanshah province, Islamic Republic of Iran. East Mediterr Health J. 2016;22:19–26.CrossRef

24.

Anand, Sudhir & World Health Organization. Measuring health workforce inequalities: methods and application to China and India. 2010. Available: https://apps.who.int/iris/handle/10665/44417. Accessed 16 Jun 2012.

25.

Erdenee O, Paramita SA, Yamazaki C, Koyama H. Distribution of health care resources in Mongolia using the Gini coefficient. Hum Resour Health. 2017. https://doi.org/10.1186/s12960-017-0232-1.

26.

Chandrashekhar Y, Alexander T, Mullasari A, Kumbhani DJ, Alam S, Alexanderson E, et al. Resource and infrastructure-appropriate management of ST-segment elevation myocardial infarction in low- and middle-income countries. Circulation. 2020. https://doi.org/10.1161/CIRCULATIONAHA.119.041297.

27.

Crilly J, Keijzers G, Tippett V, O'Dwyer J, Lind J, Bost N, et al. Improved outcomes for emergency department patients whose ambulance off-stretcher time is not delayed. Emerg Med Australas. 2015. https://doi.org/10.1111/1742-6723.12399.

28.

Kim DK, Kim TH, Shin SD, Ro YS, Song KJ, Hong KJ, et al. Impact of crowding in local ambulance demand on call-to-ambulance scene arrival in out-of-hospital cardiac arrest. Am J Emerg Med. 2022. https://doi.org/10.1016/j.ajem.2021.12.003.

29.

Miedema MD, Newell MC, Duval S, Garberich RF, Handran CB, Larson DM, et al. Causes of delay and associated mortality in patients transferred with ST-segment-elevation myocardial infarction. Circulation. 2011. https://doi.org/10.1161/CIRCULATIONAHA.111.033118.

30.

Mathews R, Peterson ED, Li S, Roe MT, Glickman SW, Wiviott SD, et al. Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry-get with the Guidelines. Circulation. 2011. https://doi.org/10.1161/CIRCULATIONAHA.110.002345.

31.

Sullivan MD, Ciechanowski PS, Russo JE, Soine LA, Jordan-Keith K, Ting HH, et al. Understanding why patients delay seeking care for acute coronary syndromes. Circ Cardiovasc Qual Outcomes. 2009. https://doi.org/10.1161/CIRCOUTCOMES.108.825471.

32.

Hutchings CB, Mann NC, Daya M, Jui J, Goldberg R, Cooper L, et al. Rapid early action for coronary treatment study. Patients with chest pain calling 9-1-1 or self-transporting to reach definitive care: which mode is quicker? Am Heart J. 2004. https://doi.org/10.1016/s0002-8703(03)00510-6.

33.

Nogueira LC Jr, Pinto LR, Silva PM. Reducing emergency medical service response time via the reallocation of ambulance bases. Health Care Manag Sci. 2016. https://doi.org/10.1007/s10729-014-9280-4.

34.

Lossius HM, Søreide E, Hotvedt R, Hapnes SA, Eielsen OV, Førde OH, et al. Prehospital advanced life support provided by specially trained physicians: is there a benefit in terms of life years gained? Acta Anaesthesiol Scand. 2002. https://doi.org/10.1034/j.1399-6576.2002.460703.x.

35.

Hagihara A, Hasegawa M, Abe T, Nagata T, Nabeshima Y. Physician presence in an ambulance Car is associated with increased survival in out-of-hospital cardiac arrest: a prospective cohort analysis. PLoS One. 2014;9:1.CrossRef

36.

Markel DT, Gold LS, Fahrenbruch CE, Eisenberg MS. Prompt advanced life support improves survival from ventricular fibrillation. Prehosp Emerg Care. 2009. https://doi.org/10.1080/10903120802706245.

37.

Henry TD, Sharkey SW, Burke MN, Chavez IJ, Graham KJ, Henry CR, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation. 2007. https://doi.org/10.1161/CIRCULATIONAHA.107.694141.

38.

Thuresson M, Jarlöv MB, Lindahl B, Svensson L, Zedigh C, Herlitz J. Factors that influence the use of ambulance in acute coronary syndrome. Am Heart J. 2008. https://doi.org/10.1016/j.ahj.2008.01.020.

39.

Romaniuk P, Szromek AR. The evolution of the health system outcomes in central and Eastern Europe and their association with social, economic and political factors: an analysis of 25 years of transition. BMC Health Serv Res. 2016. https://doi.org/10.1186/s12913-016-1344-3.

40.

Sumah AM, Baatiema L, Abimbola S. The impacts of decentralisation on health-related equity: a systematic review of the evidence. Health Policy. 2016. https://doi.org/10.1016/j.healthpol.2016.09.003.

41.

Woldemichael A, Takian A, Akbari Sari A, Olyaeemanesh A. Inequalities in healthcare resources and outcomes threatening sustainable health development in Ethiopia: panel data analysis. BMJ Open. 2019. https://doi.org/10.1136/bmjopen-2018-022923.

42.

Arcaya MC, Arcaya AL, Subramanian SV. Inequalities in health: definitions, concepts, and theories. Glob Health Action. 2015. https://doi.org/10.3402/gha.v8.27106.

43.

Lavery T, Greenslade JH, Parsonage WA, Hawkins T, Dalton E, Hammett C, et al. Factors influencing choice of pre-hospital transportation of patients with potential acute coronary syndrome: an observational study. Emerg Med Australas. 2017. https://doi.org/10.1111/1742-6723.12735.

44.

Rossello X, Bueno H, Pocock SJ, Van de Werf F, Danchin N, Annemans L, et al. Predictors of all-cause mortality and ischemic events within and beyond 1 year after an acute coronary syndrome: results from the EPICOR registry. Clin Cardiol. 2019. https://doi.org/10.1002/clc.23116.

45.

Bates ER, Jacobs AK. Time to treatment in patients with STEMI. N Engl J Med. 2013. https://doi.org/10.1056/NEJMp1308772.

Title: Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China
Authors: Siwen Li
Xuejie Dong
Dongmei Li
Hongjuan Zhang
Shuduo Zhou
Mailikezhati Maimaitiming
Junxiong Ma
Na Li
Qiang Zhou
Yinzi Jin
Zhi-Jie Zheng
Publication date: 01-12-2022
Publisher: BioMed Central
Keywords: Care
Acute Coronary Syndrome
Published in: International Journal for Equity in Health / Issue 1/2022
Electronic ISSN: 1475-9276
DOI: https://doi.org/10.1186/s12939-022-01777-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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