Effect of a Community Intervention on Patient Delay and Emergency Medical Service Use in Acute Coronary Heart Disease
The Rapid Early Action for Coronary Treatment (REACT) Trial
- Russell V. Luepker, MD;
- James M. Raczynski, PhD;
- Stravoula Osganian, MD, MPH;
- Robert J. Goldberg, PhD;
- John R. Finnegan, Jr, PhD;
- Jerris R. Hedges, MD;
- David C. Goff, Jr, MD, PhD;
- Mickey S. Eisenberg, MD, PhD;
- Jane G. Zapka, ScD;
- Henry A. Feldman, PhD;
- Darwin R. Labarthe, MD, PhD;
- Paul G. McGovern, PhD;
- Carol E. Cornell, PhD;
- Michael A. Proschan, PhD;
- Denise G. Simons-Morton, MD, PhD;
- for the REACT Study Group
- Author Affiliations: Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis-St Paul (Drs Luepker, Finnegan, and McGovern); Department of Preventive Medicine, University of Alabama, Birmingham (Drs Raczynski and Cornell); New England Research Institutes, Watertown, Mass (Drs Osganian and Feldman); Department of Cardiology, University of Massachusetts Medical School, Worcester (Drs Goldberg and Zapka); Department of Emergency Medicine, Oregon Health Sciences University, Portland (Dr Hedges); Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC (Dr Goff); Department of Medicine, University of Washington Medical Center, Seattle (Dr Eisenberg); Department of Epidemiology, University of Texas Health Science Center, Houston (Dr Labarthe); and National Heart, Lung, and Blood Institute, Bethesda, Md (Drs Proschan and Simons-Morton). A complete list of the REACT Study Group was published previously (Acad Emerg Med. 1998;5:726-738).
Abstract
Context Delayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality.
Objective To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use.
Design and Setting The Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states.
Participants A total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease–related diagnosis.
Intervention One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801).
Main Outcome Measures Time from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs.
Results General population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by −4.7% per year (95% confidence interval [CI], −8.6% to −0.6%), but the change did not differ significantly from that observed in reference communities (−6.8% per year; 95% CI, −14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly.
Conclusions In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI.
