From Italy to Bangladesh: STEMI Networks Matter

PARIS, France—From a societal perspective, primary PCI provides better overall value compared with other forms of PCI and thrombolysis, an Italian study has found.

Take Home. From Italy to Bangladesh: STEMI Networks MatterDuring a special session dedicated to STEMI networks held here today at EuroPCR, investigator Giuditta Callea, PhD (Università Bocconi, Milan, Italy), said the findings bolster the argument for a coordinated approach. “Governments should consider investing in the implementation of networks for the treatment of acute myocardial infarction, because treating patients is not only cost-effective, it saves lives,” she stressed, adding that “it is worth this kind of investment.”

Session chair Zuzana Kaifoszova, MD (HELIS Partners Consulting, Czech Republic), agreed, noting that efforts to improve STEMI care require the involvement of many stakeholders—not only healthcare professionals and economists, but educators and journalists—to raise awareness of what can be gained.

Supplying added context, another presentation in the same session described the challenges faced in Bangladesh, where delays can occur both on the way to the hospital and after patients with STEMI arrive.

Italy: Primary PCI Most Cost-Effective

For the Italy-based study, Callea and colleagues prospectively evaluated the 1-year cost-effectiveness of three different reperfusion strategies for STEMI: primary PCI, nonprimary PCI (ie, secondary PCI, rescue PCI, and pharmacoinvasive strategy), and thrombolysis. They focused on the 212 patients treated during May 2012 at public hospitals in Sicily, Italy, which lacked a STEMI network at that time. Most patients (69%) underwent primary PCI, with 20% undergoing nonprimary PCI and 3% thrombolysis. The 8% of patients who received no treatment were excluded.

Among the three study arms, there was a nonsignificant trend toward shorter symptom onset-to-treatment time for patients undergoing primary PCI versus those undergoing nonprimary PCI or thrombolysis (187 vs 466 vs 302 minutes; P = 0.06). Patients who received thrombolysis, meanwhile, were more likely to have had a previous stroke (40%) than were those who underwent primary PCI (3%) or nonprimary PCI (7%; P = 0.01).

From a societal perspective—including not only healthcare costs but also factors like follow-up care, drugs, and lost productivity—primary PCI on average cost €1,963 less than nonprimary PCI, though the difference was not significant €18,371 vs €20,334, P = 0.26). It mainly stemmed from a shorter index hospital stay. In addition, there was a nonsignificant trend toward an increase in quality-adjusted life years (QALYs) with primary versus nonprimary PCI (0.72 vs 0.69; P = 0.45). Thus, it was overall the dominant strategy at 1 year, Callea explained.

Thrombolysis was least expensive at €11,989. But its results were less favorable over 1 year compared with those of primary PCI (0.48 vs 0.72 QALYs; P = 0.03).

The researchers calculated that the probability of primary PCI being more cost-effective—at a threshold of €38,000 per QALY gained—was 92% versus nonprimary PCI and 74% versus thrombolysis.

“The results, reflecting real-world clinical practice, confirm that primary PCI represents the gold-standard treatment for STEMI, even in the absence of a well-established network for [acute MI],” Callea concluded.

Costs Not Equally Shared Among Stakeholders

Following Callea’s presentation, Mohamed Al Mutairi, MBChB (Kuwait Heart Center Chest Diseases Hospital, Hadiya, Kuwait), related his own experience in trying to persuade policy makers to spend more on STEMI care. Armed with a local study showing that a STEMI patient not given a stent will actually cost more due to longer hospital stay and the added burden of a lengthier illness, Mutairi said, he and others were able to convince the government to provide “two stents for every patient with acute coronary syndrome or STEMI, and that made a difference. The hospital stay is shorter. Less sick patients leave the hospital.”

“So I totally agree with your . . . statement that governments should invest more in providing the best care, because this will always translate into cost-effective treatment,” he said.

One difficulty, added Göran Olivecrona, MD, PhD (Lund University Hospital, Sweden), is that there are often “several players within the network. And it might be an increased cost for one of the players, but the total cost is lower.” Getting the network to act as a whole might only be possible with government supervision, “so that the net effect is cost savings,” he suggested.

Callea agreed, noting that one expense of an organized network is transportation. “In an ideal world, all patients should call the ambulance. In our case, less than 30% of patients did,” she said. “If a network exists and patients are well educated, they will call the ambulance.” This reduces transport times and likely improves outcomes, Callea noted. Now, one-third of ambulances in Sicily are equipped with ECG, she reported, which will likely introduce additional changes to the cost-effectiveness calculations.

Bangladesh: Treatment Delays, Lack of PCI Availability

In the developing world, however, the path toward a STEMI network can seem insurmountable.

Many Bangladeshi physicians were first inspired to pursue medicine by seeing American television shows—E.R., Chicago Hope, St. Elsewhere, and the like—said Tawfiq Shahriar Huq, MD (National Heart Foundation Hospital & Research Institute, Dhaka, Bangladesh). “We know that in many regions of the world, you have a phone number. When you are critically ill, you ring that number, and the rest of the things will be gradually taken care of. But in our region, [it] doesn’t work like this.”

Bangladesh is a small but densely populated country that spends only 3.7% of its gross domestic product on healthcare, Huq reported. More than 90% of healthcare expenses “are out of pocket,” he said. “There is almost no health insurance.”

In Bangladesh, Huq explained, sick patients must first discuss the matter with their family and friends and then typically visit a local traditional healer. “Once you decide to move, you have to arrange for your own transportation and finances” and find someone to accompany you and locate the nearest hospital, he continued. “When you have reached the hospital, you are not sure if this is the right place for you. Are there critical care beds available [at all]? And if there are beds, are they vacant? So you lose time.”

Tertiary cardiac care centers with cath lab facilities are clustered mainly in the capital Dhaka, and “only a handful of them provide 24/7 primary PCI service,” Huq said.

As is well known, timely reperfusion is the goal in STEMI. With this in mind, in Bangladesh the pharmacoinvasive strategy is emphasized, Huq noted. “We thrombolyze the patient at a non-PCI facility, then promptly and systematically transfer the patient to the nearest PCI facility, where PCI is performed 3 to 24 hours after the start of thrombolytic therapy.” This happens regardless of whether thrombolysis has already resulted in successful reperfusion, he added.

Between 2013 and 2014, 44.1% of STEMI patients treated at his center received the pharmacoinvasive strategy, 29.9% thrombolysis, 13.6% primary PCI, and 12.8% medical management. Patients receiving pharmacoinvasive treatment or primary PCI achieved mortality rates below 3%. The goal is to eventually be able to extend primary PCI to all STEMI patients, Huq noted.

Asked whether Bangladesh had any plans to expand PCI availability at existing centers or build new cath labs, he replied that the economic concerns are twofold: there are the costs involved in building and staffing centers plus the question of how many patients would be able to afford treatment, even if it were available.

That being said, there is progress, Huq added. “More and more patients are coming in with pharmacoinvasive therapy, and this year [as of now] we’ve already reached last year’s number of PCIs [done] at our center.”

Related Stories:

  • Callea G. Cost-effectiveness of reperfusion strategies for STEMI: real-world data from the Stent for Life Initiative in Italy. Presented at: EuroPCR 2016. May 18, 2016. Paris, France.

  • Huq TS. Pharmacoinvasive therapy: hybrid approach as a feasible alternative for STEMI in developing countries. Presented at: EuroPCR 2016. May 18, 2016. Paris, France.

  • Callea reports that her research was supported by the Italian Society of Interventional Cardiology-GISE through the Stent for Life Italia Initiative.
  • Huq reports no relevant conflicts of interest.