Million-dollar heart research
By Jim Oldfield
The Canadian Institutes of Health Research has awarded a research team led by Dr. Jack Tu $995,919 over four years. The grant is for research to measure and improve quality of care for ST-segment elevation myocardial infarction (STEMI) patients in Ontario.
One-third of heart attacks are STEMIs. Although the condition is treatable with thrombolytic (clot-dissolving) drugs or primary percutaneous coronary intervention (revascularization via a balloon-tipped catheter or other techniques, commonly called PCI), patient survival rates vary in Ontario from 7% to 14%. Tu and his team will study reasons for this regional variation, then issue report cards that will include methods for improving care in each area.
If all regions in the province achieved optimal survival rates, then the researchers estimate 600 lives could be saved each year.
"Our hypothesis is that regions with a well-organized STEMI care program, offering PCI with timely patient transfers between receiving hospitals by well-trained EMS staff, will do better," says Tu, a senior scientist in the Schulich Heart Research Program at Sunnybrook Research Institute who holds the Canada Research Chair in Health Services Research.
Only 14 hospitals in Ontario offer PCI-which has a success rate of over 90% versus 60% for thrombolytic therapy-in part because it requires a catheterization lab and a large medical team. This difference in treatment availability likely accounts for some of the regional variation in survival rates, but Tu says other factors could be at play. "It could be that patients are sicker or poorer in some regions. Those patients might be expected to have worse outcomes," says Tu, who is also a professor at the University of Toronto. "As well, there is a shortage of family doctors in certain regions in Ontario, so adequacy of primary care could be a factor, as could quality of care provided within the hospital."
Tu has assembled a multidisciplinary team of researchers to tease out which factors are affecting care in each region. The team includes researchers with expertise in methods and statistics, scientists from other provincial health care systems and interventional cardiologists who have implemented STEMI care systems with primary PCI.
One such interventional cardiologist is Dr. Harindra Wijeysundera, who manages the quality improvement component of Sunnybrook's STEMI care program. Wijeysundera has experienced the challenges of growing the program since its inception in 2007, when the standard practice at Sunnybrook was administration of thrombolytics. Sunnybrook's STEMI team now does PCI exclusively, for local patients and those in the catchment areas for North York General and Humber River Regional hospitals.
A health services scientist who will complete his PhD this year, Wijeysundera is keen to work with Tu's team. "The core group has been together for quite a while under Jack's leadership, and has produced insightful, high-impact work that has contributed to changes in care," he says.
Wijeysundera expects this grant will spur changes in STEMI care, but says those changes could be complex because the ideal treatment may not be a one-size-fits-all solution. Switching to primary PCI requires infrastructure changes, for example, that may not be feasible in some regions. Further, in the north, large distances between hospitals, along with limited access to specialists, could require that STEMI programs are highly customized for specific regions. "Our grant will not likely say, 'This is what you should do,'" says Wijeysundera. "It will prepare an inventory of the options-what works and what doesn't."
The nuance in those options will colour any controversy that emerges when the researchers make public, via the web, the regions underperforming in STEMI care. But Tu doesn't expect that nuance or controversy will hinder progress. "Our experience is that people will use this kind of data to make system improvements-even if there might be some initial anger or disbelief around unfavourable data-because clinicians want to provide the best possible care to their patients," he says.
