Abstract:
Background: A change in the Northland District Health Board (DHB) ST elevation myocardial infarction (STEMI) pathway occurred in July 2013. The pathway was changed from a primary percutaneous coronary intervention (PPCI) driven approach to a thrombolysis approach. There was a small select group of patients who continued on a PPCI pathway. The pathway was changed following a review that identified that the recommended treatment times were not being achieved suggesting that an alternative approach should be taken. It was unknown whether this change in pathway had resulted in adverse clinical outcomes and/or whether there was a change in associated costs. The change in pathway provided an opportunity to measure the two different treatments. Aim: The aim of this study was to review the Northland DHB STEMI pathways to determine the effect upon clinical outcomes and associated cost following a change in pathways. Methods: This study utilised post positivist theory as the overarching theoretical framework. The design was a retrospective cohort design study employing a quantitative methods approach. Data was retrieved from the Northland DHB clinical database for patients who had a recorded residential address within the boundaries of Northland DHB between January 2012 and February 2015 and was diagnosed with a STEMI between January 2012 and August 2014. Two comparative groups were identified; primary group (predominant PPCI pathway before the change, n=155) and thrombolysis group (predominant thrombolysis pathway after the change, n= 133). Outcome data and reimbursement data was gathered. Ethical approval for this study was obtained from the University of Auckland Human Participants Ethics Committee. Data was analysed using IBM SPSS version 21. Results: There was no statistically significant difference in clinical outcome for STEMI patients following a change in STEMI treatment pathways, clinical ends points up to six months included death, re-infarction and stroke for patients across the study groups. Although not statistically significant the change to a thrombolysis pathway was associated with an increase in cost $1,134.54 and an increase in length of stay in the thrombolysis group of 1.61 days. Other incidental findings identified that the geographical challenges of Northland reduced the treatment options for STEMI patients, a higher proportion of STEMI patients lived in lower socioeconomic environments and a ‘selective STEMI bypass’ criteria was actually meeting the needs of Whangarei residents. Conclusions: A change in the intervention pathway did not result in adverse clinical outcomes for patients who have experienced a STEMI. Additional costs were incurred as patients who had received thrombolysis therapy waited up to 72 hours for an urgent angiogram. It is recommended that the national guideline should be adopted within Northland DHB and all patients should receive an urgent angiogram within 3-24 hours. Further consideration should be given to the development of a Northland DHB Cardio Vascular Disease (CVD) governance group and future provision of a local cardiac catheter intervention facility.